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104.1-E4 Discrimination Witness Disclosure Form

Click here to download the Discrimination 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:

Nature of alleged discrimination (Check all that apply):

  Age   Marital Status
  Color   Sex
  Creed   Sexual Orientation
  National Origin   Gender Identity
  Race   Political Party Preference
  Religion   Political Beliefs
  Ancestry   Socioeconomic Status
  Physical Attributes   Familial Status
  Genetic Information   Pregnancy
  Physical/Mental Ability or Disability   Military Status
  Other - Please Specify

Description of incident witnessed (Attach addtional sheet, if needed):

Additional Pertinent Information (Attach additional sheet, if needed):

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

Witness' Signature:

Adopted: 10/17
Revised: 6/20
Related Policy: 103.1; 103.1-R; 103.1-E1-E3; 104.1; 104.1-R; 104.1-E1-E3; E5
IASB Reference: 102.E5