Complaint: Initial Report Form

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COMPLAINT: INITIAL REPORT FORM
Name of Complainant:_______________________ Location: ______________________________
Address_______________________________ Phone #: _____________ E-Mail: ________________
Date of Occurrence: ____/____/____
Date of Complaint: ___/___/___
Type of Complaint (check one):
Employee Misconduct
Program/Process
Eligibility
Discrimination
Other:______________________________________________________________
Program:
WIA
JET
ES
To be Filled Out by Grievance Officer – Describe what took place or what caused you to make this
investigation. Get all the facts, etc.
Details of Complaint (include dates/times):
_____________________________________________________________________________________
Name/Title of Parties Involved:
Persons who can provide additional Information:
Name_____________________________ Address_______________________________
Phone #: __________________________ E-Mail: _______________________________
Name_____________________________ Address_______________________________
Phone #: __________________________ E-Mail: _______________________________
W: Administration/Discrimination Log file/Grievance Initial Report Form
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