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 alleged discrimination, harassment, or bullying (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: ___________________