102.E6 - Disposition of Complaint Form

Code No. 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:  _________________________