503.5E3-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 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: __________________________