Code No. 104.E2

ANTI-BULLYING/HARASSMENT WITNESS DISCLOSURE FORM

Name of witness: ____________________________________________________

Position of witness: _________________________________________________

Date of testimony, interview: ___________________________________

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: ______________________