Code No. 104E3
DISPOSITION OF ANTI-BULLYING/HARASSMENT FORM
Date: ______________________________
Date of initial complaint: _________________________
Name of complainant (include whether the complaintant 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 | Politial Party Preference | Other-Please Specify: | |||
| Marital Status | Race/Color | ||||
| National Origin/Ethinic 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: _________________
Approved: 02/26/14
Reviewed:
Revised: 5/15/24