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):
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Nature of discrimination, harassment, or bullying alleged (check all that apply):
	Age		Physical Attribute		Sex
	Disability		Physical/Mental Ability		Sexual Orientation
	Familial Status		Political Belief		Socio-economic Background
	Gender Identity		Political Party Preference		Other - Please Specify:
	Marital Status		Race/Color
	National Origin/Ethnic Background/Ancestry		Religion/Creed

 

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:_______
Reviewed:________
Revised: