EDUCATIONAL PHILOSOPHY

Series 100

 

Policy Title: Witness Disclosure Form Code No. 102E5

 

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 alleged (check all that apply):

 

____ Age                                                                        ____ Sex

____ Disability                                                            ____ Sexual Orientation

____ Socio-economic Background                                    ____ Marital Status

____ Race/Color                                                            ____ National Origin/Ethnic                                                                                                                         Background/Ancestry

 

 

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:  __________________________________________________________________

 

 

102E5   Witness Disclosure Form                                                     4/23/25                                                             Pg. 2