Employee Complaint Form printable pdf download

Special Complaint Resolution Policy for Complaints Regarding

Certain Decisions Affecting Bonus and Incentive Payments

Employee Complaint Form

Complainant’s Name ________________________________________ Campus ___________________

Department ________________________________________________ Job Title ___________________

Mailing Address _______________________________________________________________________

Email Address _____________________________________________ Telephone __________________

Supervisor’s Name __________________________________________Telephone __________________

*************************************************************************************

If electing to have a representative involved in these proceedings:

Representative’s Name ______________________________________ Telephone __________________

Representative’s Firm/Organization _______________________________________________________

Mailing Address _______________________________________________________________________

Email Address _____________________________________________ Telephone __________________

*************************************************************************************

Complaint:

Describe your complaint in detail below, addressing each of the three points listed. Attach additional

sheets, if necessary. In addition, attach any and all documentation that supports your position.

1. Identify the decision(s) regarding bonus and/or incentive payment(s) to be reviewed, including the

name of any bonus or incentive plans involved and the relevant performance period.

2. Specify any legal and/or contractual obligations that support a reversal or modification of the

decision(s).

3. Specify the remedy you are requesting.

By signing below, the Complainant certifies that he/she has reviewed this Complaint (including any

attachments) to confirm that it is accurate and complete.

Complainant’s Signature ____________________________________________ Dated ______________

Representative’s Signature ___________________________________________ Dated _____________

Filing Instructions: This form (and all attachments) should be submitted to the Vice President for Human

Resources prior to the applicable deadline either by (a) U.S. mail or personal delivery to Human Resources – 5th

Floor, Attn: Bonus/Incentive Complaint, 1111 Franklin Street, Oakland, CA 94607, (b) facsimile to (510) 587-

6476 and prominently indicating “Attn:

Bonus/Incentive Complaint,” or (c) email (as an attachment) to

SLRG@ucop.edu

with “Attn: Bonus/Incentive Complaint” in the subject line of the email.

Employee Complaint Form