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 (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: __________________________