Regulation 33(1)
To .................... (name of questioner) of
....................(address)
1. I ....................(name of person questioned) ofE+W+S
....................(address)
hereby acknowledge receipt of the questionnaire signed by you and dated ....................
which was served on me on .................... (date).
2. [I agree that the statement in paragraph 1(2) of the questionnaire is an accurate description of what happened.]E+W+S
[I disagree with the statement in paragraph 1(2) of the questionnaire in that....................
....................]
3. I accept/dispute that my treatment of you was unlawful discrimination [harassment].E+W+S
[My reasons for so disputing are ....................
The reason why you received the treatment accorded to you and the answers to the other questions in paragraph 3 of the questionnaire are.................... ]
4. (Replies to questions in paragraph 4 of the questionnaire.)E+W+S
[5.. I have deleted (in whole or in part) the paragraph(s) numbered .................... above, since I am unable/unwilling to reply to the relevant questions in the correspondingly numbered paragraph(s) of the questionnaire for the following reasons ....................]E+W+S
....................(signature of person questioned)
....................(date)