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