EQUAL EDUCATIONAL OPPORTUNITY - WITNESS DISCLOSURE FORM
Name of Witness: |
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Date of interview:
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_____________________________________________________ |
Date of initial complaint:
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_____________________________________________________ |
Name of Complainant (include whether the Complainant is a student or employee): |
_____________________________________________________
_____________________________________________________ |
Date and place of alleged incident(s): |
_____________________________________________________
_____________________________________________________
_____________________________________________________ |
Nature of discrimination, harassment, or bullying alleged (check all that apply):
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Age |
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Sex |
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Disability |
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Sexual Orientation |
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Religion/Creed |
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Socio-economic Background |
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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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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: 8/8/2016 Reviewed: 06/09/2025 Revised: 06/09/2025