DISPOSITION OF COMPLAINT FORM
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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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_____________________________________________________
_____________________________________________________
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Date and place of alleged incident(s):
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_____________________________________________________
_____________________________________________________
_____________________________________________________
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Name of Respondent (include whether the Respondent is a student or employee):
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_____________________________________________________
_____________________________________________________
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Nature of discrimination, harassment, or bullying alleged (check all that apply):
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Age
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Physical Attribute
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Sex
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Disability
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Physical/Mental Ability
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Sexual Orientation
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Familial Status
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Political Belief
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Socio-economic Background
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Gender Identity
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Political Party Preference
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Other – Please Specify:
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Marital Status
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Race/Color
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National Origin/Ethnic Background/Ancestry
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Religion/Creed
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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: _________________________
Approved: 12/17/2018 Reviewed: 11/19/2018 Revised: 10/17/2016
