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