104.1E3 - 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):
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Age
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Physical Attribute
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Sex
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Disability
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Physical/Mental Ability
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Sexual Orientation
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Familial Status
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Political Belief
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Socio-economic Background
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Gender Identity
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Political Party Preference
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Other - Please Specify:
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Marital Status
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Race/Color
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National Origin/Ethnic Background/Ancestry
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Religion/Creed
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Remedy requested (if any): _______________________________________________________________________________________
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Summary of investigation: ________________________________________________________________________________________
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Response and action taken: ______________________________________________________________________________________
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I agree that all of the information on this form is accurate and true to the best of my knowledge.
Signature: ____________________________________ Date: _________________________
*Adopted: 12/13/10
*Revised: 08/15/11
*Reviewed: 02/8/16
*Revised: 04/04/16
*Revised: 04/04/16
*Reviewed: 02/08/21
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