102E5 Equal Educational Opportunity - Witness Disclosure Form

Code No. 102E5

EQUAL EDUCATIONAL OPPORTUNITY - WITNESS DISCLOSURE FORM

Name of Witness: __________________________________________________________

Date of interview: ____________________________________

Date of initial complaint: _____________________________________

Name of Complaintant (include whether the Complaintant is a student of employee): 

_________________________________________________________

Date and place of alleged incidents (s): _____________________________________________________________________

_____________________________________________________________________________________________________

Nature of discrimination, harassment, or bullying alleged (check all that apply):

Discription of incident witnessed: _____________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

__________________________________________________________________________________________________________

Additional Information: _______________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

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

Signature: ______________________________________________ Date: __________________________________