EMPLOYEE COMPLAINT FORM



EMPLOYEE COMPLAINT FORM

Our company takes all employee complaints—including those of discrimination, harassment, unethical conduct or safety violations, as serious matters. So that we may properly investigate your concern, you are requested to be specific and to provide as many facts as possible. Please use additional sheets of paper where needed. After a prompt and thorough investigation into your complaint, you will be notified of the company’s intended action. Thank you.

Your Name: __________________________ Today’s Date: _________________

Date that the event occurred: _________________

(If more than one event, please report each event on a separate form.)

Where did the specific event occur?

Who was involved?

Please explain what occurred in as much detail as possible:

How did you respond, what did you do?

Were there any witnesses to this specific event? (If yes, please provide their names)

Do you know of any others with similar complaints? (If yes, please provide their names)

What would be your desired outcome as a result of the investigation?

I declare that the facts set forth in this complaint form are true and accurate pursuant to the penalty of perjury under the laws of this State.

_______________________________________ _________________________________

Signature Date

Please return this form along with any supporting documentation to the HR Manager or any member of management designated to accept complaints.

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