Annie Porter Ainsworth Memorial Library

Complaint Form for Reporting Sexual Harassment

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 OELS by mailing or hand delivering it to it OELS, 5015 Campuswood Drive, East Syracuse, NY 13057, faxing it to 315-463-7846 or emailing a copy of it to sends e-mail). You will not be retaliated against for filing a complaint.

If you are more comfortable reporting verbally or in another manner, you can call OELS at 315-463-7838 to talk over how to best handle this or talk to your employer.  In either case, this form will be complete, you will be provided with a copy and you claim will be investigated according to your company’s sexual harassment prevention policy regarding as outlined at the end of this form.

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Work Address:                                                         

Work Phone:            

Job Title:                                                                    


Select Preferred Communication Method:  ☐ Email ☐ Phone  ☐In person


Immediate Supervisor’s Name:                            


Work Address:

Work Phone:                                                            


  1. Your complaint of Sexual Harassment is made about:



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 information.

Signature: __________________________     

Date: __________________

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 at sends e-mail).

Approved 12/11/18