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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): |
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Name of Respondent (include whether the Respondent is a student or employee): |
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Nature of discrimination, harassment, or bullying alleged (List specific examples):
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Summary of Investigation: _______________________________________________________________
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I agree that all of the information on this form is accurate and true to the best of my knowledge.
Signature: _____________________________________ Date: __________________________
