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104.1-E4 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 additional 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:

Return this completed form to:

Equity Coordinator/Title IX Coordinator/Affirmative Action Coordinator:
Karla Christian, Chief Officer of Human Resources
319-447-3036 /

Equity Coordinators:
Nathan Wear, Associate Superintendent (Secondary Level)
319-447-3028 /

Bob Read, Associate Superintendent (Elementary Level)
319-447-3016 /

Special Education/Student Services Equity Coordinator:
Melissa Frick, Executive Director of Student Services
319-447-3663 /

Address: 2999 N 10th Street, Marion, IA 52302
Fax: 319-377-9252       

Adopted: 10/17
Reviewed: 3/23
Revised: 6/20; 10/23
Related Policy: 104.1; 104.1-R; 104.1-E1-E3; E5
IASB Reference: 102-E(5)