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):
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Age |
Physical Attribute |
Sex |
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Disability |
Physical/Mental Ability |
Sexual Orientation |
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Familial Status |
Political Belief |
Socio-economic Background |
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Gender Identity |
Political Party Preference |
Other – Please Specify: |
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Marital Status |
Race/Color |
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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