103.E5 - 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:  ___________________________