104.E2 - Witness Disclosure Form (Discrimination, Anti-Bullying, and Anti-Harassment)

Name of Witness:______________________________________________

Date of Interview:  _____________________________

Date of Initial complaint:______________________________________

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:  __________________________