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 the Pastor or the Chairperson of the Staff – Parish Relations Committee. 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.
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Work Address: Work Phone:
Job Title: Email:
Select Preferred Communication Method: Email Phone In person
Immediate Supervisor’s Name:
Work Phone: Work Address:
Your complaint of Sexual Harassment is made about:
Work Address: Work Phone:
Relationship to you: Supervisor Subordinate Co-Worker Other
- 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.
- Date(s) sexual 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:
The last question is optional, but may help the investigation.
- 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.
This Complaint Form may be downloaded at:
Download: AUMC-Harassment-Complaint-Form (PDF)
If you have questions and to make a complaint, please contact:
Rev. Sung Ho Lee, Pastor, at 585.663.3665. or email@example.com
Aldersgate UMC Staff–Parish Relations Committee, Co–Chairs:
Jim Cobia: 585.506.2736 or firstname.lastname@example.org
Bobbi Mohrmann: 585.732.4062 or email@example.com
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