Sexual Harassment Complaint Form

Plumbers and Steamfitters Local Union No. 22
Joint Apprenticeship Training Fund

If you believe that you have been subjected to sexual harassment, you are encouraged to complete this form and submit it to the Training Coordinator of Plumbers and Steamfitters Local Union No. 22 Joint Apprenticeship Training Fund. 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

Clear

Date

Plumbers and Steamfitters Local Union No. 22
Joint Apprenticeship Training Fund

COMPLAINANT INFORMATION

SUPERVISORY INFORMATION

COMPLAINT INFORMATION

U. A. Plumbers & Steamfitters Local 22

Location

Phone

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