Employee Complaint Form printable pdf download

Employee Complaint Form

EMPLOYEE COMPLAINT FORM

Policy GAE

Check Complaint Level:

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Name of Complainant:____________________________________________________________

School/Facility/Department:_______________________________________________________

Mailing Address:_________________________________________________________________

_________________________________________________________________

Home Phone Number:___________________ Office or Cell Phone Number:_________________

Complaint Made To (Name/Title): ___________________________________________________

Statute, Policy, Rule, or Regulation Involved:

Reference or description of statute, policy, rule, or regulation alleged or have been violated or

misapplied:

Facts as to Violation and Effect on Complainant:

Brief statement of allegations describing the date of the occurrence of the most recent

incident or matter on which the complaint is based and the violation or misapplication of

the statute, policy, rule, or regulation:

Statement as to how the alleged violation or misapplication substantially affects

Complainant in the employment relationship:

Statement of Relief Sought by Complainant (attach additional page if needed):

The undersigned employee hereby makes this complaint pursuant to the Policy GAE of the Board

of Education and affirms that the facts stated above are true and correct.

Date:______________________

Employee Signature:________________________________

Date Received:_______________ Administrator Signature______________________________

Employee Complaint Form