The City University of New York
Sexual Misconduct Complaint 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.
Ca
mpus ______________________________________
Received by____________________ Date ___________
PART A (PLEASE PRINT OR TYPE)______________________________________________
Name: ______________________________________________________________________
Email Address: _______________________________________________________________
Contact/Cell Number: _________________________________________________________
Status (e.g. Faculty, Staff, Student, Visitor): ________________________________________
Campus Address (e.g. Building or Department): _____________________________________
Home Address: _______________________________________________________________
PART B_______________________________________________________________________
Summary of Sexual Misconduct Complaint
1. Alleged sexual misconduct took place on or about:
Month __________________ Day __________ Year ____________
Other dates/times? ______________________________________
Is th
e alleged sexual misconduct continuing? YES NO
2. Accused/Respondent Name(s) _________________________________________
Title (if known) _____________________________________________________
3. Please describe the incident(s) or facts regarding your complaint- what occurred? (Add extra sheets if
needed). __________________________________________________________________________
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4. Please identify any witnesses or other individuals with information regarding your allegations.
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5. I affirm that the above allegation is true to the best of my knowledge, information, and belief.
S
ignature: __________________________________
Date: ________________________
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