Code No. 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, 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:  __________________________