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MONROE-WOODBURY CENTRAL SCHOOL DISTRICT (Monroe-Woodbury Central School District)

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MONROE-WOODBURY CENTRAL SCHOOL DISTRICT
Complaint Form for Reporting
Sexual Harassment
1120-E.1
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. This form is intended to be used
by both students and employees.
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 the Building Principal or Title IX Officer. You will not be retaliated
against for filing a complaint.
If you are more comfortable reporting verbally or in another manner, the district will 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 : https://www.ny.gov/programs/combating-
sexual-harassment-workplace
YOUR INFORMATION (for all persons making a complaint)
Your name: ________________________Name of student (for parents/guardians): _____________________
Home Address: ____________________________________________________________________________
Home or Cell Phone: _______________________Email: ___________________________________________
School (for students): ___________________________Grade/Class (for students): _____________________
Work Address (for employees): ________________________________________________________________
Work Phone (for parents/guardians/employees): __________________________________________________
Job Title (for employees): _____________________________________________________________________
Preferred Communication Method (please select one): phone email mail in person
SUPERVISOR INFORMATION (for employees)
Immediate Supervisor’s Name: ______________________________________Title: ______________________
Work Phone:_____________________ Work Address: _____________________________________________
COMPLAINT INFORMATION (for all persons making a complaint)
1. Your complaint of sexual harassment is made against:
Name: ____________________________________________ Job Title (if an employee): _______________
Grade/Class (if a student): _________________________________________________________________
School Address/Work Location (if known): _________________________ Phone (if known): ____________
Relationship to you (please check one below):
(for employees)
Supervisor Subordinate Co-Worker Student Other
(for students)
Teacher Other staff member Other student Other
For employees or students, please describe 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 or education. Please use
additional sheets of paper if necessary and attach relevant documents or evidence.
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:
The following question is optional, but may help the district’s investigation.
5. Have you previously complained about or provided information (verbal or written) about sexual
harassment or related incidents to the district? NoYes
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.
_______________________________________________________________________________________
Print Name: __________________________________________ Date: ________________________
Signature: __________________________________________
Monroe-Woodbury Title IX Officers:
Matthew Kravatz, Assistant Superintendent for Human Resources
Kristin Randhare, Director of Educational Support Services
Instructions for the District
If you receive a complaint about sexual harassment, you must follow the district’s sexual harassment
prevention policy by investigating the allegation through the 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 (if the complainant is a student, also notify the parent/guardian) and the individual(s)
against whom the complaint was made. This may be done via email.
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Completed 23 December 2020

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