WITNESS DISCLOSURE FORM
Name of Witness: Date of interview:
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Date of initial complaint:
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Name of Complainant (include whether the Complainant is a student or employee):
Date and place of alleged incident(s):
Nature of harassment, or bullying alleged (check all that apply):
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Age |
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Sex |
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Disability |
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Sexual Orientation |
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Race/Color |
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Socio-economic Background |
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Marital Status |
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National Origin/Ethnic Background/Ancestry |
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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:
