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104 E2 Witness Disclosure Form

104 E2 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/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: __________________________

Date Board Adopted: 11-19-2007

Date Board Reviewed and Updated: 10-16-2017