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

 

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:  _________________________

Approved March 8, 2021
Reviewed June 26, 2024
Revised March 8, 2021