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

Date:

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Date of initial complaint:

_____________________________________________________

Name of Complainant (include whether the Complainant is a student or employee): 

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_____________________________________________________

 

 

Date and place of alleged incident(s):

_____________________________________________________

_____________________________________________________

_____________________________________________________

Name of Respondent (include whether the Respondent is a student or employee):

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_____________________________________________________

_____________________________________________________

 

 

 

 

 

 

 

 

Nature of discrimination, harassment or bullying 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:

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