Disposition of Complaint Form – Discrimination, Anti-Bullying, Anti-Harassment

Code No. 104.0E3
DISPOSITION OF COMPLAINT FORM
Date: ______________________________________________________________
Date of initial complaint: __________________________________________________________________
Name of Complainant (include whether the Complainant is a student or employee):
__________________________________________________________________
__________________________________________________________________
Date and place of alleged incident(s):
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Name of Respondent (include whether the Respondent is a student or employee):
__________________________________________________________________
__________________________________________________________________
Nature of discrimination, harassment, or bullying alleged (check all that apply):
Age
Physical Attribute
Sex
Disability Physical/Mental Ability Sexual Orientation
Familial Status Political Belief Socio-economic Background
Gender Identity Political Party Preference Other – Please Specify:
Marital Status Race/Color
National Origin/Ethnic
Background/Ancestry Religion/Creed
Summary of Investigation: ______________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
I agree that all of the information on this form is accurate and true to the best of my knowledge.
Signature: ____________________________ Date: _________________________
Approved 5/16/16Code No. 104.0E3
DISPOSITION OF COMPLAINT FORM
Date: _____________________________________________________
Date of initial complaint: _____________________________________________________
Name of Complainant (include
whether the Complainant is a
student or employee):
_____________________________________________________
_____________________________________________________
Date and place of alleged
incident(s):
_____________________________________________________
_____________________________________________________
_____________________________________________________
Name of Respondent (include
whether the Respondent is a
student or employee):
_____________________________________________________
_____________________________________________________
Nature of discrimination, harassment, or bullying alleged (check all that apply):
Age Physical Attribute Sex
Disability Physical/Mental Ability Sexual Orientation
Familial Status Political Belief Socio-economic Background
Gender Identity Political Party Preference Other – Please Specify:
Marital Status Race/Color
National Origin/Ethnic
Background/Ancestry Religion/Creed
Summary of Investigation: ______________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
I agree that all of the information on this form is accurate and true to the best of my knowledge.
Signature: ____________________________ Date: _________________________
Approved 5/16/16