104.E2 - 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: __________________________