104-E2 - Anti-Bullying/Harassment Policy - Witness Disclosure Form

Policy 104-E(2): Anti-Bullying/Harassment Policy

 

WITNESS DISCLOSURE FORM

 

Name of Witness: _____________________________________________________

 

Date of interview: _____________________________________________________

 

Date of initial complaint: _______________________________________________

 

Name of Complainant (include whether the Complainant 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		Political Party Preference		Other – Please Specify:
	Marital Status		Race/Color
	National Origin/Ethnic Background/Ancestry		Religion/Creed

 

Description of incident witnessed: _______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

 

Additional information: _______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

 

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

 

Signature: _____________________________________ Date:__________________________

 

 

Case Law References Description

Morse v. Frederick 551 U.S. 393 (2007)

 

Approved: April 3, 2023

Reviewed: April 3, 2023

Revised: April 3, 2023