Name of complainant: _________________________________________________________________
Position of complainant: ________________________________________________________________
Name of student or employee target: _______________________________________________________
Grade and Building of student or employee: _________________________________________________
Date of initial complaint: _______________________________________________________________
Name and position or grade of alleged perpetrator/respondent: __________________________________
Nature of Discrimination or Harassment Alleged (Check all that apply.)
___ Age ___ Physical Attribute ___ Sex
___ Disability ___ Political Belief ___ Sexual Orientation
___ Familial Status ___ Race/Color ___ Socio-economic Background
___ Marital Status ___ Religion/Creed ___ Other – Please Specify
___ National Origin/Ethnic Background/Ancestry
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: / /
