SEXUAL HARASSMENT FORM

If you believe that you have been subjected to sexual harassment or gender discrimination, you are encouraged, but not required, to complete this form. When you click “Submit” your form will be sent to us and reviewed by our human resources department. No employee will be retaliated against for filing a complaint.

If you are more comfortable reporting verbally or in another manner, please contact Lance Herman (lance@starhg.com) or Wilmary Rodriguez (wrodriguez@starhg.com) or call us at 212.661.6148.

Complainant Information

First Name *

Last Name *

Email *

Phone *

Select Preferred Communication Method

Prefered Communication Method

• Email
• Phone
• In Person

Supervisory Information

Supervisor's First Name

Supervisor's Last Name

Complaint Information

Your complaint of sexual harassment is made about

First Name

Last Name

Work Location

Relationship To You

Supervisor

Supervisee

Co - Worker

Other (Please Specify)

Please describe what happened and include as many details as possible

Date(s) Sexual Harassment Occurred (start)

Date(s) Sexual Harassment Occurred (end date)

Is the sexual harassment continuing?

• Yes
• No

If possible, please list the name and contact information of any witnesses or individuals who may have information related to your complaint:

Have you previously provided information (verbal or written) about related incidents? If yes, when and to whom did you provide information?

Captcha

Submit