104.E3 - Disposition of Complaint Form


 

Code No. 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:  __________________________