102-E5 - Equal Educational Opportunity - 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 alleged (check all that apply):

	Race		Religion
	Color		Sexual Orientation
	National Origin		Age
	Sex		Actual or potential parental, family or marital status
	Disability		Pregnancy or related conditions
	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: __________________________

Approved: April 13, 2026

Reviewed: April 13, 2026

Revised: April 13, 2026

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