You are here

104.1-E2 - Anti-Bullying/Harassment Witness Disclosure Form

 

 

 

Name of Witness:
Position of Witness:
Date of Testimony/Interview:
Date of Initial Complaint:

Nature of discrimination, harassment, or bullying alleged (check all that apply):

  Age   Physical Attribute   Sex
  Disability   Physical/Mental Ability   Sexual Orientation
  Familial Status   Political Belief   Socio-Economic Background
  Gender Identity   Political Party Preference   Other: Please Specify
  Marital Status   Race/Color  
  National Origin/Ethnic Background/Ancestry   Religion/Creed

Description of Incident Witnessed (include date and place of incident):
____________________________________________________________________________________________
____________________________________________________________________________________________

Any Other Information:
_____________________________________________________________________________________________
_____________________________________________________________________________________________

I agree that all of the information is accurate and true to the best of my knowledge.

SIgnature: __________________________________________________ Date: _____________________________


Reviewed: 5/14; 9/16
Related Policy (Code#): 104.1; 104.1-R; 104.1-E1, E3