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105.1-E5 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   Physical Attribute   Sex
  Disability   Physical or Mental Ability   Sexual Orientation
  Familial Status   Political Belief   Socio-Economic Background
  Gender Identity   Political Party Preference   Other - Please specify below
  Marital Status   Race/Color  
  National Origin/Ethnic Background/Ancestry   Religion/Creed

Description of incident witnessed:
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Additional Information:
__________________________________________________________________________________________________
__________________________________________________________________________________________________

I agree that all the information on this form is accurate and true to the best of my knowledge.

Signature:
Date:


Adopted: 10/17
Related Policy (Code #): 105.1; 105.1-R; 105.1-E1-E4, E6