102.E5 - 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 alleged (check all that apply):
	Race       Religion   Color       Sexual Orientation   National Origin       Age   Sex       Actual or potential parental, family, or marital status   Disability     Pregnancy or related conditions   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:  ___________________________________