104.2WF - 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): _______________________________________________
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Nature of discrimination, harassment, or bullying alleged (check all that apply):
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Age
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Physical Attribute
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Sex
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Disability
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Physical/Mental Ability
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Sexual Orientation
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Familial Status
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Political Belief
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Socio-economic Background
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Gender Identity
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Political Party Preference
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Other - Please Specify:
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Marital Status
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Race/Color
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National Origin/Ethnic Background/Ancestry
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Religion/Creed
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Description of incident witnessed:__________________________________________________________________________________
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Additional information: ___________________________________________________________________________________________
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I agree that all of the information on this form is accurate and true to the best of my knowledge.
Signature: ____________________________________ Date: _________________________
*Adopted: 12/13/10
*Reviewed: 05/14/12
*Revised: 02/8/16
*Revised: 04/04/16
*Reviewed: 02/08/21
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