104.1-E5 Discrimination Disposition of Complaint Form




Click here to download Policy 104.1-E5 - Discrimination Disposition of Complaint Form

Today's Date:
Name of Complainant (include whether the complainant is a student or employee):
Date of Initial Complaint:
Date and Place of Alleged Incident:
Name of Respondent (include whether the respondent is a student/employee/volunteer):

Nature of alleged discrimination (Check all that apply):

  Age   Martial Status   Other - Please specify below:
  Color   Sex
  Creed   Sexual Orientation
  National Origin   Gender Identity
  Race   Political Party Preference
  Religion   Political Beliefs
  Ancestry   Socioeconomic Status
  Physical Attributes   Familial Status
  Genetic Information   Pregnancy
  Physical/Mental Ability or Disability   Military Status

Summary of Investigation:

I agree that the information on this form is accurate and true to the best of my knowledge.

Equity Coordinator's Signature:

Adopted: 10/17
Revised: 6/20
Related Policy (Code#): 103.1; 103.1-R; 103.1-E1-E3; 104.1; 104.1-R; 104.1-E1-E4
IASB Reference: 102.E6