102.E6 - 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

 

Race / Color

 

Disability

 

Sex

 

Religion / Creed

 

 

 

Marital Status

 

Sexual Orientation

 

National Origin/Ethnic Background/Ancestry

 

Socio-economic Background

 

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:  _________________________