104.E3 - Disposition of Complaint Form

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 harassment, or bullying alleged (check all that apply):

	Age		Sex
	Disability		Sexual Orientation
	Race/Color		Socio-economic Background
	Marital Status
	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: