|
Date:
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_____________________________________________________ |
|
Date of initial complaint:
|
_____________________________________________________ |
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Name of Complainant (include whether the Complainant is a student or employee): |
_____________________________________________________
_____________________________________________________ |
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Date and place of alleged incident(s): |
_____________________________________________________
_____________________________________________________
_____________________________________________________ |
|
Name of Respondent (include whether the Respondent is a student or employee): |
_____________________________________________________
_____________________________________________________ |
Nature of harassment, or bullying alleged (list specific example): ____________________________________________________________________
________________________________________________________________________________________________________________________
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: 07/14/2025 Revised: 07/14/2025