102.E6 - Disposition of Complaint Form

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

 

Physical Attribute

 

Sex

 

Disability

 

Physical/Mental Ability

 

Sexual Orientation

 

Familial Status

 

Political Belief

 

Socio-economic Background

 

Gender Identity

 

Political Party Preference

 

Other – Please Specify:

 

Marital Status

 

Race/Color

 

 

National Origin/Ethnic Background/Ancestry

 

Religion/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:  _________________________

 

 

Adopted:          07/16/2007
Revised:           01/09/2017
Reviewed:        02/20/2023

 

dawn.gibson.cm… Thu, 07/22/2021 - 13:08