103.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):

 

Age

 

Religion

 

Disability

 

Creed

 

Gender Identity

 

Sex

 

Marital Status

 

Sexual Orientation

 

National Origin

 

Socioeconomic Status

 

Race/Color

 

Other – Please Specify

 

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:  __________________________