502.11E3 - Disposition of Complaint Form

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): 

  

_____________________________________________________

 

_____________________________________________________
   

 

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:  __________________________