104.E3 Disposition of Complaint Form

Code No. 104.E3

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: August 15, 2016

Reviewed:

Revised: