102.E5 - Witness Disclosure Form

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

 

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:  __________________________

dawn.gibson.cm… Mon, 10/30/2023 - 09:03