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
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City of Plattsburgh
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 Senior Payroll Personnel Associate contact person, Julie Winterbottom. 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:
Work Address: Work Phone:
Job Title: Email:
Select Preferred Communication Method: Email Phone In person
Immediate Supervisor’s Name:
Work Phone: Work Address:
Model Complaint Form for
Reporting Sexual Harassment
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1. Your complaint of Sexual Harassment is made about:
Name: Title:
Work Address: 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
Signature: __________________________ Date: __________________
click to sign
click to edit
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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.