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104.E3 Disposition of Anti-Bullying/Harassment Complaint Form

Code No. 104.E3

DISPOSITION OF ANTI-BULLYING/HARASSMENT COMPLAINT FORM

Name of complainant:

Name of student or employee target:

Grade and building of student or employee:

Name and position or grade of

Alleged perpetrator/respondent

Date of initial complaint:

Nature of discrimination or harassment 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
  • Marital Status
  • Race/Color
  • National Origin/Ethnic Background/Ancestry
  • Religion/Creed
  • Other Please Specify 

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:

Updated 2-18-2019      Reviewed 7-25-2022