Complaint Form For Reporting Sexual Harassment

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.

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[Name of employer]

New York State Labor Law requires all employers to adopt a sexual harassment prevention policy that

includes a complaint form for employees 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 [person or office designated; contact information for designee or office; how the form can be

submitted]. Once you submit this form, your employer must follow its sexual harassment prevention policy and

investigate any claims.

If you are more comfortable reporting verbally or in another manner, your employer is still required to follow its

sexual harassment prevention policy by investigating the claims as outlined at the end of this form.

For additional resources, visit: ny.gov/combatting-sexual-harassment

COMPLAINANT INFORMATION

Name:

Home Address: Work Address:

Home Phone: Work Phone:

Job Title: Email:

Select Preferred Communication Method:

(please select one)

SUPERVISORY INFORMATION

Immediate Supervisor’s Name:

Title:

Work Phone: Work Address:

COMPLAINT INFORMATION

1. Your complaint of Sexual Harassment is made against:

Name: Title:

Work Address: Work Phone:

Complaint Form For

Reporting Sexual Harassment

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.

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Relationship to you: Supervisor Subordinate Co-Worker Other

2. Please describe the conduct or incident(s) that is the basis of this complaint and your reasons for

concluding that the conduct is sexual harassment. 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 that may have

information related to your complaint:

The last two questions are optional, but may help facilitate the investigation.

5. Have you previously complained or provided information (verbal or written) about sexual

harassment at [Name of employer]? If yes, when and to whom did you complain or provide

information?

Employees that file complaints with their employer might have the ability to get help or file claims

with other entities including federal, state or local government agencies or in certain courts.

6. Have you filed a claim regarding this complaint with a federal, state or local government agency?

Yes No

Have you instituted a legal suit or court action regarding this complaint?

Yes No

Have you hired an attorney with respect to this complaint?

Yes No

I request that [name of employer] investigate this complaint of sexual harassment in a timely and

confidential manner as outlined below, and advise me of the results of the investigation.

Signature: __________________________ Date: __________________

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.

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Instructions for Employers

If you receive a complaint about alleged sexual harassment, you must follow your sexual

harassment prevention policy by investigating the allegations through actions such as:

 Speaking with the employee

 Speaking with the alleged harasser

 Interviewing witnesses

 Collecting and reviewing any related documents

You should create a written document of the findings of the investigation, along with any corrective

actions taken and notify the employee and the individual(s) against whom the complaint was made.

This may be done via email.