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103.1-E3 - Anti-Bullying/Anti-Harassment Disposition of Complaint Form


Name of Person Filing Complaint (Complainant):
Relationship of Complainant to District:
Date of Initial Complaint:
Name of Alleged Victim:
Grade or Position and Building of Alleged Victim:
Date and Place of Alleged Incident:
Name and Grade/Position of Alleged Bully/Harasser:

Nature of alleged bullying/harassment (Check all that apply):

  Age   Marital Status
  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
  Other - Please Specify

Summary of Investigation (Attach an additional sheet, if needed):

I agree that all of the information is accurate and true to the best of my knowledge.

Signature of Equity Coordinator:

Reviewed: 5/14; 9/16; 3/23
Revised: 6/20
Related Policy: 103.1; 103.1-R; 103.1-E1-E2
IASB Reference: 104-E(3)