Sexual Harassment Complaint Form

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 Jerilee DiLalla, Assistant Superintendent for Human Resources and Title IX Coordinator (585-637-1912). Forms may be submitted electronically below, by email to jerilee.dilalla@bcs1.org, by USPS mail to Jerilee DiLalla, 40 Allen St. Brockport, NY 14420 or in person. 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


Sexual Harassment Complaint Form

COMPLAINANT INFORMATION

Name: 

Job Title: 

 Work Address: 

Work Phone: 

Email:

Select Preferred Communication Method: 

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: 

2. Please describe what happened and how it is affecting you and your work. Please send any relevant documents or evidence to jerilee.dilalla@bcs1.org. 

3. Date(s) sexual harassment occurred: 

Is the sexual harassment continuing? 

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.



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