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
  • 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.


Adopted: Unknown
Revised/Reviewed: 10.7.2019

Reviewed 01.17.2022