Union Presbyterian Church

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 copy the form below and paste it onto a blank document; then, fill out the form and submit it by:

Emailing it to Rev. Patricia Raube at pastor@upcendicott.org

OR

Mailing it to:

Rev. Patricia Raube
Union Presbyterian Church
200 East Main Street
Endicott, NY 13760

Please mark the envelope “Confidential.”
You will not be retaliated against for filing a complaint.

If you are more comfortable reporting verbally or in another manner, your employer should 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: ny.gov/programs/combating-sexual-harassment-workplace

COMPLAINANT INFORMATION

Name:                                                                                                      

Work Address:                                                   Work Phone:                  

Job Title:                                                             Email:                              

Select Preferred Communication Method:         Email   Phone   In person

 SUPERVISORY INFORMATION

 Immediate Supervisor’s Name:                      

 Title:                         

 Work Phone:                                                      Work Address:      

 COMPLAINT INFORMATION

1.    Your complaint of Sexual Harassment is made about:

Name:                                                            Title:                    

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: __________________