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, 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:  ___________________________________