|
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 |
|
|
Religion/Creed |
Political Party Preference |
Other – Please Specify: |
|
|
Marital Status |
Race/Color |
|
|
|
National Origin/Ethnic Background/Ancestry |
|
|
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: 07/01/2025
Reviewed: 07/01/2025
