Sexual Harassment Complaint Form

Bloomingdale School of Music

SEXUAL HARASSMENT COMPLAINT FORM

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 the Senior Director of Operations. 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
example@example.com
Select Preferred Communication Method:

EmailPhoneIn-person
SUPERVISORY INFORMATION
Immediate Supervisor's Name
Title
Work Phone
Work Address
COMPLAINT INFORMATION
1. Your complaint of Sexual Harassment is made about:
Name
Title
Work Address
Work Phone
Relationship to you:

SupervisorSubordinateCo-workerOther
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.
File Upload

Cancelof
3. Date(s) sexual harassment occurred:
Is the sexual harassment continuing?

YesNo
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

Clear
Date

MonthDayYear
Date
Should be Empty:

Bloomingdale School of Music

SEXUAL HARASSMENT COMPLAINT FORM

COMPLAINANT INFORMATION

SUPERVISORY INFORMATION

COMPLAINT INFORMATION