102.E5 - Witness Disclosure Form

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):

           

 

	Age		Sex
	Disability		Sexual Orientation
	Race/Color		Socio-economic Background
	Marital Status
	National Origin/Ethnic Background/Ancestry

 

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: