104.E2 - Witness Disclosure Form

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: ____________________

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