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		Race / Color
	Disability		Sex
	Religion / Creed
	Marital Status		Sexual Orientation
	National Origin/Ethnic Background/Ancestry		Socio-economic Background

 

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:  __________________________