104.E2 Anti-Bul/Harass. Witness Disclosure Form

WITNESS DISCLOSURE FORM

 Name of Witness:

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_____________________________________________________

 

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:  _________________