0110.2-E Sexual Harassment of Employees Exhibit

New York State Labor Law requires all employers to adopt a sexual harassment prevention policy that includes a complaint form for targets 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 to the best of your ability and submit it to [insert title, person or office designated; contact information for designee or office; how the form can be submitted]. You will not be retaliated against for filing a complaint.

If you are more comfortable reporting verbally or in another manner, the district 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: http://www.ny.gov/programs/combating-sexual-harassment-workplace

 

YOUR INFORMATION (for all persons making a complaint)

Your Name:
Home Address:
Home or Cell Phone:
Email:
Work Address:
Work Phone:
Job Title:
Preferred Communication Method (please select one): phone, email, mail, in person

 

SUPERVISOR INFORMATION

Immediate Supervisor’s Name:
Title:
Work Phone:
Work Address:

 

COMPLAINT INFORMATION

1. Your complaint of Sexual Harassment is made against (please include as much information as possible, if known):

Name:
Job Title (if an employee):
Grade/Class (if a student):
School/Work Location:
Phone:
Relationship to you (please circle one below):
Supervisor / Subordinate / Co-Worker / Student / Other: ______________________

(Please use additional sheets of paper if the complaint is against multiple people.)

 

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.
 

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3. Date(s) and location(s) sexual harassment occurred: _____________________

 

Is the sexual harassment continuing? ____ Yes ____ No

 

4. Please list the name and contact information (if known) of any witnesses or individuals who may have information related to your complaint:

 

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5. Have you previously complained about or provided information (verbal or written) about sexual harassment or related incidents to the district? ____ Yes ____ No

If yes, when and to whom did you complain or provide information?

 

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If you have retained legal counsel and would like us to work with them, please provide their contact information.

 

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Print Name: _________________________

 

Signature: __________________________

 

Date: __________________

 

Instructions for the District

If you receive a complaint about alleged sexual harassment, you must follow the district's sexual harassment prevention policy by investigating the allegations through actions including:

• Speaking with the complainant
• Speaking with the alleged harasser
• Interviewing witnesses
• Collecting and reviewing any related documents

While the process may vary from case to case, all allegations should be investigated promptly and resolved as quickly as possible. The investigation should be kept confidential to the extent possible.

Document findings of the investigation and basis for your decision along with any corrective actions taken and notify the complainant and the individual(s) against whom the complaint was made (if the alleged harasser is a student, also notify the parent/guardian). This may be done via email.

 

Sent to the Board of Education for Information:            05/21/20   
Approved by the Board of Education:                06/18/20