Cayuga County Community College

Sexual Harassment Complaint Form


This form is to be used for filing a complaint alleging sexual harassment, consistent with the College's Sexual Harassment Policy and Procedures.

Please respond to each of the following items.

1. Name

Street Address City State Zip Code

3. Telephone Number ( Include Area Code)__________________________

4. Date of Birth________________________________________________

5. What is the specific incident(s) that has caused you to file a sexual harassment complaint? Please describe in detail relevant information including persons involved, times, dates, places, witnesses, and if applicable, any College activity involved.






6. Date(s) when alleged incident(s) first occurred.

Month Day Year


7. Did you attempt to resolve the complaint by contacting the individual(s) against whom the complaint is directed?

________ ________
Yes No


8. If yes, please describe the steps that were taken to try to resolve the complaint, and the results of those steps. Include persons involved, times, places, and witnesses.







I understand that submission of this form grants the Affirmative Action Officer my permission to conduct a full investigation of the above complaint. This investigation may involve review of confidential documents and interviews with relevant persons, including college employees and other witnesses.


Signature Date



Office Use Only:

Date of Receipt: _________________________

Received by: ________________________________________________________