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102.E5 WITNESS DISCLOSURE FORM

Code No. 102.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:  __________________________