104.E3 Anti-Bul/Haras. Disp. Complaint Form

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:  ________________