Code No. 104E2
ANTI-BULLYING/HARASSMENT COMPLAINT FORM
Name of witness: _________________________________________________________________
Position of witness: _______________________________________________________________
Date of statement interview: ________________________________________________________
Description of incident observed: ____________________________________________________
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Any other information: _____________________________________________________________
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I agree that all of the information on this form is accurate and true to the best of my knowledge.
Signature: _________________________________________________ Date: _________________
Assisting Staff Member Signature (if appropriate): _______________________________________
Approved: 02/26/14
Reviewed:
Revised: 04/14/2021