104.E2 Witness Disclosure Form

Code No. 104.E2

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: February 21, 2012

Reviewed: August 15, 2016

Revised: August 15, 2016