Sexual Harrassment Complaint FormTOWN OF WAPPINGER
Sexual Harassment Complaint Form
Effective 10/9/2018
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 a Board designated H.R. Manager or Town Supervisor. 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:
Job Title:
Select Preferred Communication Method
SUPERVISORY INFORMATION
Immediate Supervisor's Name:
Title
Work Phone:
Email:
❑Email ❑Phone ❑In person
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 page 1 of 3
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-
bout:
Name-
Name:
Work
Work Address:
Title:
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:
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Instructions for Employers
If you receive a complaint about alleged sexual harassment, follow your sexual harassment
prevention policy.
An investigation involves:
• Speaking with the employee
• 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 the findings of the investigation and basis for your decision 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.
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