Sexual Harassment Complaint Form – Print-friendly version
New York State Labor Law requires all employers to adopt a sexual harassment prevention policy that includes a complaint form to report alleged incidents of sexual harassment.
If you believe that you have been subjected to sexual harassment, you are encouraged to complete this form and submit it to Sarah Blood, School Business Administrator. You will not be retaliated against for filing a complaint.
If you are more comfortable reporting verbally or in another manner, your employer should complete this form, provide you with a copy and follow its sexual harassment prevention policy by investigating the claims as outlined at the end of this form.
For additional resources, visit: ny.gov/programs/combating-sexual-harassment-workplace
COMPLAINANT INFORMATION
Name:
Work Address:
Work Phone:
Job Title:
Email:
Select Preferred Communication Method:
Email
Phone
In person
SUPERVISORY INFORMATION
Immediate Supervisor’s Name:
Title:
Work Phone:
Work Address:
Adoption of this form does not constitute a conclusive defense to charges of unlawful sexual harassment. Each claim of sexual harassment will be determined in accordance with existing legal standards, with due consideration of the particular facts and circumstances of the claim, including but not limited to the existence of an effective anti-harassment policy and procedure.
COMPLAINT INFORMATION
1. Your complaint of Sexual Harassment is made about:
Name:
Title:
Work Address:
Work Phone:
Relationship to you:
Supervisor
Subordinate
Co-Worker
Other
2. Please describe what happened and how it is affecting you and your work. Please use additional sheets of paper if necessary and attach any relevant documents or evidence.
3. Date(s) sexual harassment occurred:
Is the sexual harassment continuing?
Yes
No
4. Please list the name and contact information of any witnesses or individuals who may have information related to your complaint:
The last question is optional, but may help the investigation.
5. Have you previously complained or provided information (verbal or written) about related incidents? If yes, when and to whom did you complain or provide information?
If you have retained legal counsel and would like us to work with them, please provide their contact information.
Signature:
Date: