102.E5 Witness Disclosure Form

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: __________________________

Approved: June 20, 2016

Reviewed:

Revised: