Harassment, Discrimination and Hate Speech Reporting Form (Victory Staff Only)

Staff Name(Required)

First Last

Name of person reporting the incident(Required)

Email Address of Person Reporting(Required)

Cellphone Number of Person Reporting(Required)

Is the person reporting the incident also the alleged victim?(Required)

Yes

No

If not, what is the name of the alleged victim?

What was the date of the incident?(Required)

What was the approximate time of the incident?(Required)

:

Where did it occur (including whether it happened on conference grounds, if unclear)?(Required)

What are the names of witnesses (if any)?(Required)

What did the person reporting the incident say happened?(Required)