502.10E2 - 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:                          

 

 

Approved    4/11/05                        
Reviewed   11/15/21                                                                      
Revised