Employee Concern/Complaint Form

Employee Concern/Complaint Form

If you have a complaint or concern, or experience a problem that affects you or your co-workers. We ask that you complete this form immediately after the incident or problem first occurred. IWF management will contact you.
Full Name / Nombre completo*
Name of Jobsite/Company / Nombre del lugar de trabajo/empresa*
Date of incident / Fecha del incidente*

MonthDayYear
Supervisor’s name/Nombre del supervisor*
Witnesses/Testigos
Phone Number/Numero de Telefono*
Email/Correo Electronico*
Describe accurately the details of your complaint and against whom/Describa con precisión los detalles de su queja y contra quién::*
Describe how the incident you are complaining about has impacted negatively on your work/Describa cómo el incidente del que se queja ha impactado negativamente en su trabajo:*
Describe how the company can deal effectively with your complaint/Describa cómo la empresa puede tratar eficazmente su queja::
Did do you report the incident? To whom? Date? / ¿Reportaste el incidente? ¿A quien? ¿Fecha?
Give additional comments which you believe will be important during further investigations of your complaint/Proporcione comentarios adicionales que crea que serán importantes durante futuras investigaciones de su queja::
By my signature below, I confirm that I am submitting this report in good faith and the information provided above accurately reflects my recollection of the incidents related to my complaint.

Con mi firma a continuación, confirmo que envío este informe de buena fe y que la información proporcionada anteriormente refleja con precisión mi recuerdo de los incidentes relacionados con mi queja.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: