Code No.: 104.0E2
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: __________________________
Approved 2/15/93
Reviewed 7/26/99
Reviewed 12/19/02
Reviewed 7/7/08
Reviewed 3/7/11
Revised 2/2/15
Revised 5/16/16
