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

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): 

_____________________________________________________

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:  __________________________