Code No. 104E3
DISPOSITION OF ANTI-BULLYING/HARASSMENT FORM
Name of complainant: __________________________________________________________________
Name of student or employee harmed: _______________________________________________________
Grade and building of student or employee: __________________________________________________
Name and position or grade of Alledged perpertrator/respondent: _________________________________
Date of initial complaint: ________________________________________________________________
Nature of Bullying or Harassment 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 ______________________
__ Religion/Creed __ National Origin/Ethnic __ Background/Ancestry
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: 04/14/2021