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                                                      _____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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