104.E2 - Witness Disclosure Form

Name of Witness: 
Date of interview: 
Date of initial complaint: 
Name of Complainant (include whether the Complainant is a student or employee): 
Date and place of alleged incident(s): 

Description of incident witnessed: 

 

Additional information: 

 

I agree that all of the information on this form is accurate and true to the best of my knowledge.

 

Signature: _______________________________Date:_______________
Approved: 4-21-25 Reviewed: 7-21-25 Revised: 7-21-25