Fillable Witness Statement THE SCHOOL DISTRICT OF PALM BEACH (Palm Beach Schools)

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Witness Statement THE SCHOOL DISTRICT OF PALM BEACH (Palm Beach Schools)

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THE SCHOOL DISTRICT OF PALM BEACH COUNTY
This form MUST be completed when there is a witness to an incident of alleged student harassment and/or discrimination. One form must be
completed for each witness. All Witness Statements that relate to one incident should be attached to the Student Complaint Report (PBSD
1615) at the time the complaint report is sent to the Regional Superintendent, EEO (Equal Employment Opportunity) / Title IX Coordinator,
ADA (American with Disabilities Act) / 504 Specialist, and Age Act (Age Discrimination Act) Coordinator.
Witness Statement
Description of incident(s) witnessed
OFFICE OF PROFESSIONAL STANDARDS
PBSD 1616 (Rev. 4/6/2021) ORIGINAL- Regional Superintendent COPY - Principal COPY - Complainant
COPY - EEO/Title IX Coordinator COPY - ADA/504 Specialist COPY - Age Act Coordinator
I agree that all of the information on this form is accurate and true to the best of my knowledge.
SIGNATURE OF WITNESS
DATE
Witness First Name M.I. Last Name Interview Date
School School Phone #
Incident DatePrincipal Person Completing Form
Witness Title
I agree that all of the information on this form is accurate and true to the best of my knowledge.
Other information
PBSD 1616 (Rev. 4/6/2021) ORIGINAL- Regional Superintendent COPY - Principal COPY - Complainant
COPY - EEO/Title IX Coordinator COPY - ADA/504 Specialist COPY - Age Act Coordinator
SIGNATURE OF WITNESS
DATE
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Witness Statement THE SCHOOL DISTRICT OF PALM BEACH (Palm Beach Schools)

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Completed 8 February 2022

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