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
- Disability
- Familial Status
- Gender Identity
- Marital Status
- National Origin/Ethnic Background/Ancestry
- Physical Attribute
- Physical/Mental Ability
- Political Belief
- Political Party Preference
- Race/Color
- Religion/Creed
- Sex
- Sexual Orientation
- Socio-economic Background
- 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:
Adopted: Unknown
Revised/Reviewed: 10.7.2019
Reviewed 01.17.2022
