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 alleged (check all that apply):
_____Race                                                            ____Religion
_____Color                                                          _____Sexual Orientation
_____ National Origin                                          _____Age
_____Sex                                                            _____Actual or potential parental, family, or marital status
_____Disability                                                 _____Pregnancy or related conditions
_____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: __________________________