|
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):
q Race
q Religion
q Color
q Sexual Orientation
q National Origin
q Age
q Sex
q Actual or potential parental, family or marital status
q Disability
q Pregnancy or related conditions
q Creed
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: _________________________
