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):
_____________________________________________________________________________
_____________________________________________________________________________
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Nature of discrimination, harassment, or bullying alleged (check all that apply): |
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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: _______________
