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):
______________________________________________________________________________________________________
Description of incident(s) witnessed:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Additional information: _________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
I agree that all of the information on this form isaccurate and true to the best of my knowledge.
Signature: _____________________________________
Date: __________________________
Approved: April 3, 2023; October 27, 2025
Reviewed: April 3, 2023; October 27, 2025
Revised: April 3, 2023; October 27, 2025