Employee Relations - Complaint Form - The University Of Tennessee

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EMPLOYEE RELATIONS ~ COMPLAINT FORM
Human Resources encourages you to contact Employee Relations regarding your workplace complaints/concerns. Please submit
this form for further review, to Human Resources, in accordance to the University of Tennessee Health Science Center
(UTHSC) Policy and Procedures.
Employee Name (Complainant): ____________________________________________________________ Date: ________________
Job Title: __________________________________________________ Department/College: __________________________________
Contact Number: _______________________________________ Email Address: ___________________________________________
Complaint Regarding:
_________ Faculty
__________ Staff
_________ Student
Other (specify): ____________________________
Employee Name (Respondent): _______________________________________________Date of Incident: __________________
Job Title: _____________________________________________________ Department/College_________________________________
Contact Number: _____________________________________________ Email Address: _____________________________________
Describe your complaint in detail and attach any additional sheets if needed.
Code of Conduct Violated
(specify): _____________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Witnesses: ___________________________________________________________________________________________________________
Have you raised this complaint/concern with other University Officials: The Office of Equity and Diversity
(OED), Faculty Affairs, Campus Police and/or the Office of Compliance Review, etc.? _______ No _______ Yes
If yes, please specify. ________________________________________________________________________________________________
Resolution Requested:
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Human Resources
910 Madison Ave. Suite, 722
Memphis, TN 38163
901-448-5600

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