104.E3 - Disposition of Anti-Bullying/Harassment Complaint Form

Name of complainant:  ____________________________________________________________

Name of student or employee target:  _________________________________________________

Grade and building of student or employee:  ___________________________________________

Name and position or grade of alleged perpetrator/respondent:  ____________________________
_______________________________________________________________________________

Date of initial complaint:  __________________________________________________________

Nature of Discrimination or Harassment 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:  ____________________

 

 

Approved    07/19/07                             
Reviewed  10/18/21  
Revised _09/08/08