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 _____Sexual Orientation _____Physical/Mental Ability
_____Gender Identity _____Familial Status _____Socio-economic Background _____ Political Belief _____Marital Status _____Political Party Preference _____Race/Color _____Religion/Creed
_____National Origin/Ethnic Background/Ancestry _____Other – Please Specify: ____________
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: _________________________
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|
Approved: 12/9/24 |
Reviewed |
Revised |