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:  ___________________________________