* Required

Canandaigua City School District

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 Brian Nolan. 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:required

Work Address:required

Work Phone:

Job Title:required

Email:

Select Preferred Communication Method:*

Email Phone In person

Supervisory Information

Immediate Supervisor's Name:

Title:

Work Phone:

Work Address:required

Complaint Information

Adoption of this form does not constitute a conclusive defense to charges of unlawful sexual harassment. Each claim of sexual harassment will be determined in accordance with existing legal standards, with due consideration of the particular facts and circumstances of the claim, including but not limited to the existence of an effective anti-harassment policy and procedure.

1. Your complaint of Sexual Harassment is made about:

Name:required

Title:

Work Address:required

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 along with any relevant documents or evidence below.required

Attach additional sheets, documents and evidence

Max file size: 10 MB

3. Date(s) sexual harassment occured:required

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:

This question is optional, but my 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.

Signaturerequired

Date:required (mm/dd/yyyy)

Please provide an email address where we can send a link to your current form.

Email Address :