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: __________________________
