104.E3 - Disposition of Anti-Bullying/Harassment 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)

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:

       /         /