102.E5 - Witness Disclosure Form
102.E5 - Witness Disclosure Form
Code No. 102.E5
WITNESS DISCLOSURE FORM(discrimination)
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Name of Witness: |
_____________________________________________________
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Date of interview:
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_____________________________________________________ |
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Date of initial complaint:
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_____________________________________________________ |
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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 alleged (check all that apply):
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Race |
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Regilion |
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Color |
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Sexual Orientation |
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National Origin |
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Age |
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Sex |
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Actual or potential parental, family or marital status |
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Disability |
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Pregnancy or related conditions |
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Creed |
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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: ______________________
Adopted: 11/19/2007
Revised: 05/12/2026
Reviewed: 05/12/2026