502.11E3 - Disposition of Complaint Form

Date:	_____________________________________________________
Date of initial complaint:	_____________________________________________________
Name of Complainant:	_____________________________________________________ _____________________________________________________
Date and place of alleged incident(s):	_____________________________________________________ _____________________________________________________ _____________________________________________________
Name of Respondent (include whether the Respondent is a student or employee):	_____________________________________________________ _____________________________________________________

Nature of 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: __________________________

dawn.gibson.cm… Fri, 04/14/2023 - 13:23