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):	_____________________________________________________   _____________________________________________________   _____________________________________________________

 

 

Description of incident(s) 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:  __________________________