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Name of Witness:
Position of Witness (Student/Employee/Volunteer):
Date of Interview:
Date of Initial Complaint:
Description of Incidents Witnessed (Include date and place of incidents):
____________________________________________________________________________
____________________________________________________________________________
Additional Pertinent Information:
____________________________________________________________________________
____________________________________________________________________________
I agree that all of the information is accurate and true to the best of my knowledge.
Witness's Signature:
Date:
Return this completed form to:
Equal Employment/Nondiscrimination Coordinator/Title IX Coordinator:
Karla Christian, Chief Human Resources Officer
319-447-3036 / kchristian@Linnmar.k12.ia.us
Nondiscrimination Coordinator:
Nathan Wear, Associate Superintendent
319-447-3028 / nathan.wear@Linnmar.k12.ia.us
Special Education/Student Services Nondiscrimination Coordinator:
Anne Faber, Executive Director of Student Services
319-730-3663 / anne.faber@Linnmar.k12.ia.us
Address: 3556 Winslow Road, Marion, IA 52302
Fax: 319-403-8008
Reviewed: 5/14; 9/16; 3/23
Revised: 6/20; 10/23; 9/24; 9/25
Related Policy: 103.1; 103.1-R; 103.E1; 103.1-E3
IASB Reference: 104-E(2)