Employee Complaint
Tell us what happened in the form below.
Your name:
Date of Complaint
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Month
-
Day
Year
Date
Who are you making a complaint about?
Location of Incident
Date and approximate time of incident:
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Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Describe accurately the details of your complaint:
Describe how the incident you are complaining about has impacted negatively on your work:
Is there anything that we can do to improve the situation?
Give additional comments which you believe will be important during further investigations of your complaint:
If there were others who witnessed the incident, please provide their names:
Is this the first time that you have raised concerns about this person?
Yes
No
By signing you declare that all information you have given here is truthful and accurate.
Signature
Supervisor’s comments:
Submit Complaint
Should be Empty: