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You are here: Home / Board of Education / Witness Disclosure Form – Discrimination, Anti-Bullying, Anti-Harassment

Witness Disclosure Form – Discrimination, Anti-Bullying, Anti-Harassment

Code No.: 104.0E2
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: __________________________
Approved 2/15/93
Reviewed 7/26/99
Reviewed 12/19/02
Reviewed 7/7/08
Reviewed 3/7/11
Revised 2/2/15
Revised 5/16/16

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High School

209 Sadie Street
Anamosa, IA 52205

319-462-3594
Call Now
319-462-2332
Office Fax
319-462-2503
Guidance Fax

Middle School

410 Old Dubuque Rd, Anamosa, IA 52205

319-462-3553
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319-462-3309
Fax Number

Strawberry Hill

203 Hamilton St, Anamosa, IA 52205

319-462-3549
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319-462-5317
Fax Number

District Office

200 S Garnavillo St, Anamosa, IA 52205

319-462-4321
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319-462-4322
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