102.E5- Witness Disclosure Form

Name of Witness:                                                                                            

Date of interview:                                                                                             

Date of initial complaint:                                                                                           

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

Religion/Creed

Political Party Preference

Other – Please Specify:

Marital Status

Race/Color

National Origin/Ethnic Background/Ancestry