Job Aid: Complaint Form for Reporting Harassment

Purpose: Use this job aid if you wish to report harassment.

Instructions for use: You can print this document or recreate the form in a word processing or spreadsheet application.

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 according to your company's harassment prevention policy. Once you submit this form, your employer must follow its sexual harassment prevention policy and investigate the claim. You are not required to use this form. 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.

Complainant information
Item	Information
Name:
Home Address:
Work Address:
Home Phone:
Work Phone:
Job Title:
E-mail:
Select Preferred Communication Method (Please Select One):

Supervisory information
Item	Information
Immediate Supervisor's Name:
Title:
Work Phone:
Work Address:

Complaint information

1. Your complaint of harassment is made against:

Name: __________________________________________________________________

Title: ___________________________________________________________________

Work Address: ___________________________________________________________

___________________________________________________________

Work Phone: _____________________________________________________________

Relationship to you: Supervisor ____ Subordinate ____ Co-Worker ____ Other ____

2. Please describe the conduct or incident(s) that is/are the basis of this complaint and your reasons for concluding that the conduct is harassment. Please use additional sheets of paper if necessary and attach any relevant documents or evidence.

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

3. Date(s) 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:

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

5. Have you previously complained or provided information (verbal or written) about the harassment? If yes, when and to whom did you complain or provide information?

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

NOTE: Individuals who 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 my employer investigate this complaint of sexual harassment in a timely and confidential manner, and advise me of the results of the investigation.

Signature: ___________________________________________ Date: __________________

Course: Workplace Harassment Prevention for Employees, State of New York
Topic: More Information