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 (List specific examples):

 

 

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:  __________________________