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):

_____________________________________________________

_____________________________________________________

_____________________________________________________

 

 

Nature of discrimination, harassment, or bullying alleged (check all that apply):

 

Age

 

Physical Attribute

 

Sex

 

Disability

 

Physical/Mental Ability

 

Sexual Orientation

 

Familial Status

 

Political Belief

 

Socio-economic Background

 

Gender Identity

 

Political Party Preference

 

Other – Please Specify:

 

Marital Status

 

Race/Color

 

 

National Origin/Ethnic Background/Ancestry

 

Religion/Creed

 

 

 

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:  ________________________

 

 

Revised:           01/09/2017
Reviewed:        02/20/2023