104.E2 - Witness Disclosure Form (Dec 2025)

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 is accurate and true to the best of my knowledge. 

Signature: _____________________________________ 

Date:  __________________________