Student Statement Form

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Please ask if you have questions or need explanations
1. Write only what you saw someone do or heard someone say.
2. Be as SPECIFIC as possible (when, where, what time, how, who what, etc.)
3.Due to confidentiality, please do not discuss the conversations in the office about this event with anyone
4. You understand that you tell an untruth that you will be disciplined

Statement *

Print name of witness(s) *

Statement understanding

By submitting this form I attest that I have read and understand the requirements above. I know that I may be disciplined if I tell an untruth on someone. The account that I gave above is based on things that I have actually witnessed myself. I will not discuss this event with anyone. I wrote this account of my own freewill.

Name *

Student ID # *

Date *

YYYY

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