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104.1-E3 - Disposition of Anti-Bullying/Harassment

 

 

 

Date of Initial Complaint:
Name of Complainant/Target:
Grade/Position and Building of Complainant/Target:
Date and Place of Alleged Incident:
Name and Grade/Position of Alleged Perpetrator/Respondent:

Nature of discrimination, harassment, or alleged bullying (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 is accurate and true to the best of my knowledge.

SIgnature: __________________________________________________ Date: _____________________________


Reviewed: 5/14; 9/16
Related Policy (Code#): 104.1; 104.1-R; 104.1-E1-E2