106.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:  ________________________________