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Full Name
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First Name
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Phone Number
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Email Address
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Preferred method of contact
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Phone
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What is your time preference to be contacted? (Select all that apply)
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Morning 8:00 AM - 12:00 PM
Afternoon 12:00 PM - 5:00 PM
Evening 5:00 PM - 8:00 PM
What type of concern are you reporting? (Please select all that apply)
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Harrasment
Discrimination
Unprofessional Conduct
Safety or Security Issue
Privacy or Confidentiality Concern
Service Quality Issue
Other
Who was involved in the incident?
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Date(s) and time(s) of the incident
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Location(s) of the incident
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Please describe what happened
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Were there any witnesses?
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How urgent is this concern to you?
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Immediate attention needed
High priority
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What would you like to see happen as a result of the complaint?
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Do you consent to HR reviewing and investigating this complaint?
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I confirm that the information provided is accurate to the best of my knowledge.
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