Code No. 102.E5
WITNESS DISCLOSURE FORM
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Name of Witness: |
_____________________________________________________ |
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Date of interview: |
_____________________________________________________ |
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Date of initial complaint: |
_____________________________________________________ |
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Name of Complainant (include whether the Complainant is a student or employee): |
_____________________________________________________
_____________________________________________________ |
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Date and place of alleged incident(s): |
_____________________________________________________
_____________________________________________________
_____________________________________________________ |
Nature of discrimination, harassment, or bullying alleged (check all that apply):
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Age |
Race / Color |
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Disability |
Sex |
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Religion / Creed |
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Marital Status |
Sexual Orientation |
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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: __________________________
