Sexual Harassment Complaint Form - East Greenbush Community Library

Complainant Information

Name

First

Last

Job title

Work address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email

Select preferred communication method:

Email
Phone
In person

Supervisory Information

Immediate supervisor's name

First

Last

Supervisor's title

Work address

Address Line 1

Address Line 2

City

State

Zip Code

Supervisor's phone

Complaint Information

Your complaint of sexual harassment is made about:

First

Last

Title

Work address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Relationship to you

Supervisor
Subordinate
Co-worker
Other

If other, please specify:

Please describe what happened and how it is affecting you and your work. Please attach any relevant documents or evidence.

Upload attachments (optional)

Drag & Drop Files, Choose Files to Upload

Date harassment occurred

Is the sexual harassment continuing?

Yes
No

Please list the name and contact information of any witnesses or individuals who may have information related to your complaint.

Have you previously complained or provided information (verbal or written) about related incidents?

Yes
No

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.

Date

Your Library

Services

Complaint Form for Reporting Sexual Harassment

Complainant Information

Supervisory Information

Complaint Information