LGPS Grievance Submission Form

LGPS Grievance Submission Form
Do you want to submit this grievance anonymously?
Details of Event Leading Grievance
Date and Time of Event

MonthDayYear
Date
Hour MinutesAM/PM Option
Location of Event
Nature of Concern
Description of Incident
Please provide a detailed information. Include the names of persons involved.
Witnesses (if applicable)
Impact on You or Others
How did this affect you or others? (e.g., emotional, professional, or relational impact)
Desired Outcome or Resolution
What would help you feel heard or supported? (e.g., apology, clarification, facilitated discussion, organizational changes, other)
Additional Comments
Anything else you want us to know?
Attach additional documents if needed

Cancelof
Would you like a Safety Contact or designated mediator to follow up with you directly if needed? If "Yes", please provide contact below. Select "No" if you wish to remain anonymous.
Contact email for follow-up (optional)
example@example.com
Name (optional)

First NameLast Name
Reconciliation Process
Once submitted, your grievance will be received by the LGPS Safety Contact Team. Anonymous submissions will be handled with care, and efforts will be made to facilitate dialogue or reconciliation when possible. Submissions may be aggregated to identify patterns and inform organizational improvement.
Date of Submission

MonthDayYear
*Submission of this grievance affirms that the information you have provided is accurate to the best of your knowledge.
Should be Empty:

Details of Event Leading Grievance