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The City University of New York Sexual Misconduct (CUNY Queensborough Community College)

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The City University of New York
Sexual Misconduct Allegation Form
This form may be used by reporting individuals or complainants, including employees, students and
visitors, who wish to file a complaint of sexual harassment, gender-based harassment and/or sexual
violence pursuant to CUNY’s Policy on Sexual Misconduct. CUNY’s policy prohibits retaliation
against any person who reports sexual misconduct, assists someone making such a report, participates in
any manner in an investigation or resolution of a sexual misconduct complaint, seeks interim or supportive
measures or accommodations pursuant to CUNY’s Policy on Sexual Misconduct, or opposes in a
reasonable manner an act or policy believed to constitute sexual misconduct.
Campus
Date filed
PART A.
Name:
Email Address:
EMPL ID Number
Contact/Cell Number:
Status (e.g. Student, Alumnus,Faculty, Staff, Visitor):
Home Address:
1. Have you previously filed a complaint?
Yes No
a.
If so, when and to whom did you file it?
2. Have you filed this allegation with a federal, state or local law enforcement/agency?
Yes No
a.
If yes, with which agency?
b.
When?
c.
If no, why?
d.
Do not want to report Need assistance in reporting Other
e.
If you chose other, please state the reason:
3. Do you have an order of protection (OOP) in this matter?
Yes No
a.
If yes, is this order permanent or temporary?
Permanent
Temporary Next Court Date
4. Was OOP given to your campus Public Safety Office
?
Y
es
No
a.
If yes, when and to whom?
PART B
Summary of Sexual Misconduct Allegation
1.
Alleged sexual misconduct took place on or about:
Mon
th Day Year Tim
e
a.
Is the alleged sexual misconduct continuing? YES NO
b. Whe
re did the alleged sexual misconduct take place
?
c.
(
location address
)
2.
Respondent Name(s)
Tit
le (if know
n)
3.
Is the Respondent a CUNY
Student Staff Faculty Alum Visitor
a.
I
f not, what is respondent’s relationship to you?
4.
Was this allegation previously reported to any one of the following (select one below):
5.
Please describe the events and circumstances underlying your allegation of Sexual Misconduct - (Add
extra sheets if needed).
6.
Pleaseidentifyany witnesses orotherindividualswithinformationregardingyourallegations.
7.
Please preserve any evidence in your possession that may be used as part of the investigation of this
m
atter. Evidence may include but it not limited to: (i.e Facebook, Instagram, Snapchat, TikTok, Twitter
,
Wha
tsapp, photos, other documents, et
c.)
Y
es
No
8.
Are you in need of any support services on campus? (select one below)
9.
I would like this allegation(s) investigated by the Title IX Office.
Y
es
No
10.
I acknowledge and agree that by clicking “Submit” will act as my electronic signature to this Sexual
Misconduct Allegation Form, as well as my affirmation that the above allegation(s) is true to the best of
my knowledge, information and belief.
Complainant Signature:
Date:
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The City University of New York Sexual Misconduct (CUNY Queensborough Community College)

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Completed 3 February 2021

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