LGPS Grievance Submission Form

LGPS Grievance Submission Form
Do you want to submit this grievance anonymously?*

YesNo
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.*

YesNo
Contact email for follow-up (optional)
example@example.com
Name (optional)

First NameLast Name
Reconciliation Process*

I agree to participate in a facilitated reconciliation process if invited and if appropriate for the concern I have submitted.I decline to participate in any facilitated reconciliation process at this time. I understand that my concern will still be reviewed and that declining participation may limit the scope of possible outcomes.
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.*

I acknowledge that this submission will be reviewed by the LGPS Safety Contact Team and that any follow up or response will depend on the information I provide. I recognize that the goal of this process is to support understanding, repair when possible, and the well being of the community.
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:

LGPS Grievance Submission Form

Details of Event Leading Grievance