Stockbridge-Munsee Community (SMC)
Initial Employee Anti-Harassment Form
Initiating the Anti-Harassment Process: I understand by completing the initial employee Anti-Harassment form this does not constitute
it as a violation to the Anti-Harassment Policy. The form will be reviewed by the Employee Relations Representative to define what
will warrant an investigation in accordance to the Employment Manual, as well as Chapter 53 (SMC Employee Rights Ordinance).
(Alleged Target) Employee name / Contact Info:
(Alleged Harasser) Employee name / Contact Info:
Employee is submitting anti-harassment form for the following reasons:
___ Forms of harassment that interfere with job performance or create a hostile or offensive working environment including, but not limited to
intimidating or discourteous conduct, including harassing or discourteous emails, persistently bothering, disturbing or tormenting another person,
as well as derogatory jokes or comments relating to race, color, national origin, age, handicap, religion, sex or sexual orientation. EMPLOYEE
PROVIDES: 1) What has been violated by page and section, and 2) Supporting documentation of alleged incident.
___ Unwelcome verbal or physical contact of a sexual nature includes, but is not limited to, deliberately and repeatedly making unsolicited
gestures or comments of a sexual nature, displaying offensive sexually graphic materials, verbal or physical conduct of a sexual nature, whether or
not repeated, that is sufficiently severe to interfere substantially with an employee’s work performance or to create an intimidating, hostile or
offensive work environment. EMPLOYEE DEFINES: Sexual offensive and EMPLOYEE PROVIDES: Supporting documentation of alleged
violation.
___ Retaliation or reprisal against any employee who files a complaint or provides information related to the complaint. EMPLOYEE
DEFINES: Retaliation or reprisal, and EMPLOYEE PROVIDES: Supporting documentation of alleged violation.
Please initial by each line that documents have been attached to form for submission.
_______Timeline of events (date(s), time(s), place(s), people involved, etc.)
______ Emails, letters, messages (voice, social media or etc.), surveillance footage or etc.
______ Witnesses (First and last name, department and job title)
Employee requests the following solution to resolve the complaint. If the request is fulfilled, the matter is closed:
Employee Signature: _________________________________________________ Date: _______________________
Confidentiality - As an employee of SMC who has initiated the Anti-Harassment Process I agree to adhere to strict
confidentiality. I agree not to repeat any of the information I may hear as part of the Anti-Harassment Process. I
understand that if I break confidentiality I will be subject to disciplinary action.
Retaliation - I also understand that the SMC will not tolerate any retaliation against any employee who files a
complaint/grievance or provides information related to the complaint/grievance Remember to keep your focus on
your work and keep your interaction neutral, civil and job related. SMC does expect you to be cordial and polite.
It’s not OK to refuse to speak to the person or spread rumors or false accusations. Violation of these simple rules
could result in disciplinary action.
Date Received: ________________
Representative:
________________
