102.E5 - Witness Disclosure Form
102.E5 - Witness Disclosure Form|
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): |
_____________________________________________________ _____________________________________________________ _____________________________________________________ |
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Nature of discrimination, harassment, or bullying alleged (check all that apply):
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Age |
Marital Status |
Sex |
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Disability |
Race/Color |
Sexual Orientation |
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Religion/Creed |
National Origin/Ethnic Background/Ancestry |
Socio-economic Background |
Description of incident witnessed: _________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Additional information: _________________________________________________________________
_____________________________________________________________________________________
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I agree that all of the information on this form is accurate and true to the best of my knowledge.
Signature: _____________________________________ Date: ______________________
Adopted: 11/19/2007
Revised: 07/01/2025
Reviewed: 07/01/2025