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103.1-E2 - Anti-Bullying and Anti-Harassment Witness Disclosure Form


Name of Witness:
Position of Witness (Student/Employee/Volunteer):
Date of Interview:
Date of Initial Complaint:

Nature of alleged bullying/harassment (Check all that apply):

  Age   Marital Status
  Color   Sex
  Creed   Sexual Orientation
  National Origin   Gender Identity
  Race   Political Party Preference
  Religion   Political Beliefs
  Ancestry   Socioeconomic Status
  Physical Attributes   Familial Status
  Genetic Information   Pregnancy
  Physical/Mental Ability or Disability   Military Status
  Other - Please specify

Description of Incident Witnessed (Include date and place of incident):

Additional Pertinent Information:

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

Witness's Signature:

Return this completed form to:

Equity Coordinator/Title IX Coordinator/Affirmative Action Coordinator:
Karla Christian, Chief Officer of Human Resources
319-447-3036 /

Equity Coordinators:
Nathan Wear, Associate Superintendent (Secondary Level)
319-447-3028 /

Bob Read, Associate Superintendent (Elementary Level)
319-447-3016 /

Special Education/Student Services Equity Coordinator:
Melissa Frick, Executive Director of Student Services
319-447-3663 /

Address: 2999 N 10th Street, Marion, IA 52302
Fax: 319-377-9252

Reviewed: 5/14; 9/16; 3/23
Revised: 6/20; 10/23
Related Policy: 103.1; 103.1-R; 103.1-E1, E3
IASB Reference: 104-E(2)