Employee Complaint Process - Step I Initial Employee Complaint Form printable pdf download

Appendix 2-4

Employee Complaint Process – Step I

Initial Employee Complaint Form

Any employee who wishes to file a complaint must fill out this form completely and turn it in to the

employee’s supervisor.

Name of Complainant:________________________________ Building: ___________________________

____________________________/__________________________ / _____________________________

Date cause of complaint occurred

Date complaint was submitted

Person to whom form was submitted

Please state your complaint, including how you have been harmed. Please be specific and include dates:

_____________________________________________________________________________________

Please describe any efforts you have made to resolve your complaint informally and the responses to your

efforts:

_____________________________________________________________________________________

With whom did you communicate (list dates): ________________________________________________

_____________________________________________________________________________________

Please describe the outcome or remedy you seek for this complaint:

_____________________________________________________________________________________

If additional space is needed in reporting for Step I, please attach additional sheets.

________________________________________________

______________________

Employee Signature

Date

Please note: Attach to this form any documents you believe will support the complaint. Please keep a

copy of the completed form and any supporting documentation for your records.

Employee Complaint Process - Step I Initial Employee Complaint Form