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102.E6 DISPOSITION OF 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:  _________________________

 

Approved:  8/8/2016                                              Reviewed:  ______________                                   Revised:  ___________________