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, 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:  __________________________