104E2 Anti-Bullying/Harassment Witness Disclosue Form

Code No. 104E2

ANTI-BULLYING/HARASSMENT WITNESS DISCLOSURE FORM

Name of witness: _________________________________________________________________

Date of nterview: _________________________________

Date of initial complaint: ____________________________________

Name of Complainant (include whether the coomplaintant is a student or employee):

__________________________________________________________

Date and place of alleged incident(s): _____________________________________________________

___________________________________________________________________________________

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		Politial Party Preference		Other-Please Specify:
	Marital Status		Race/Color
	National Origin/Ethinic Background/Ancestry		Religion/Creed

Description of incident witnessed: ____________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Any other information: _____________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

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

Signature: _________________________________________________ Date: _________________

Approved:  02/26/14
Reviewed:
Revised: 5/15/24