Code No. 102.E5
WITNESS DISCLOSURE FORM
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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): |
_____________________________________________________
_____________________________________________________
_____________________________________________________ |
Nature of discrimination, harassment, or bullying alleged (check all that apply):
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Age |
Physical Attribute |
Sex |
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Disability |
Physical/Mental Ability |
Sexual Orientation |
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Familial Status |
Political Belief |
Socio-economic Background |
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Political Party Preference |
Other – Please Specify: |
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Marital Status |
Race/Color |
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National Origin/Ethnic Background/Ancestry |
Religion/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: __________________________