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):
_____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: __________________________
