Discrimination/harassment Witness Statement

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Form Title: Discrimination/Harassment Witness Statement
Form #401.3F2
Date of Interview: __________________________________________________________
Interviewer: _______________________________________________________________
Name of Person Giving Statement: _____________________________________________
Position and Building of Witness: ______________________________________________
Home Address:
___________________________________________________________________________
___________________________________________________________________________
Home Telephone: (
)_______________________________________________________
Statement: (Include dates, places and persons involved if known.)
I agree that all of the information on this form is given in good faith and is accurate and true
to the best of my knowledge.
Signature: ____________________________________________________________________
Name Printed: ________________________________________________________________
Date:

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