102.E(5) - 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: _________________________

I.C. Iowa Code Description

Iowa Code § 216.6 Unfair Employment Practices

Iowa Code § 216.9 Unfair/Discriminatory Practices

Iowa Code § 256.11 DE - Educational Standards

Iowa Code § 280.3 Education Program - Attendance Center Requirements

I.A.C. Iowa Administrative Code Description

281 I.A.C. 12 General Accreditation Standards

U.S.C. - United States Code Description

20 U.S.C. §§ 1221 Education - FERPA - General Provisions

20 U.S.C. §§ 1681 Education - Sex

20 U.S.C. §§ 1701 Education - EEO

29 U.S.C. § 206 Labor - Minimum Wage

29 U.S.C. §§ 794 Labor - Vocation Rehab Rights

42 U.S.C. § 12101 Public Health - Equal Opportunity - Disabilities

42 U.S.C. § 2000d Public Health - Civil Rights - Federally Programs

42 U.S.C. § 2000e Public Health - EEO Civil Rights - Definitions

C.F.R. - Code of Federal Regulations Description

34 C.F.R. Pt. 100 Education - Nondiscrimination for Programs

34 C.F.R. Pt. 104 Education - Nondiscrimination on Basis of Handicap

Cross References Description

101 Educational Philosophy of the School District

104 Anti-Bullying/Harassment Policy

104-R(1) Anti-Bullying/Harassment Policy - Investigation Procedures

104-E(1) Anti-Bullying/Harassment Policy - Complaint Form

104-E(2) Anti-Bullying/Harassment Policy - Witness Disclosure Form

104-E(3) Anti-Bullying/Harassment Policy - Disposition of Complaint Form

401.01 Equal Employment Opportunity

502.03 Student Expression and Student Publications Code

502.03-R(1) Student Expression and Student Publications Code - Regulation

506.01 Education Records Access

506.01-R(1) Education Records Access - Regulation

Cross References Description

506.01-E(1) Education Records Access - Request of Nonparent for Examination or Copies of Education Records

506.01-E(2) Education Records Access - Authorization for Release of Education Records

506.01-E(3) Education Records Access - Request for Hearing on Correction of Education Records

506.01-E(4) Education Records Access - Request for Examination of Education Records

506.01-E(5) Education Records Access - Notification of Transfer of Education Records

506.01-E(6) Education Records Access - Letter to Parent Regarding Receipt of a Subpoena

506.01-E(7) Education Records Access - Juvenile Justice Agency Information Sharing Agreement

506.01-E(8) Education Records Access - Annual Notice

603.01 Basic Instruction Program

802.05 Buildings & Sites Adaptation for Persons with Disabilities

Approved: 9/17/2018, 9/18/2023, 11/18/2024, 12/15/2025, 8/19/2026

Reviewed: 7/22/2026

Revised: 7/22/2026

dawn.gibson.cm… Wed, 06/24/2026 - 19:56