Code No. 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: __________________________