Grievance, Discrimination, Harassment, and/or Bullying *Employee Report Form*

1
Name* This field is required.
First Name
Last Name
2
Job Title* This field is required.
3
Email* This field is required.
example@example.com
Confirm Email
4
School/Department* This field is required.
5
Select the Report Type* This field is required.
Bullying
Discrimination
Grievance
Harassment
6
Date of Occurrence:* This field is required.
Date
Month
Day
Year
7
Have you discussed this issue with your supervisor?* This field is required.
Yes
No
8
Supervisor's Name* This field is required.
9
Employee Statement* This field is required.
Please list specific problem(s)/issue(s).
10
For clarification of the issues of your grievance or incident of discrimination, harassment, and/or bullying please provide statements regarding the unfavorable employment decision/condition which is the subject of this report.* This field is required.
Describe what happened, when and where, how your employment has been affected, and indicate names of others involved.
11
Upload any supporting documentation.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
12
Resolution Requested* This field is required.
Indicate the action(s) that would resolve your grievance.
13
My signature indicates that the information contained on this form and attachments to this form are true and factual to the best of my knowledge. * This field is required.
Clear
14
Date* This field is required.
Date
Month
Day
Year
15
Grievance Policy* This field is required.1750/7220 Policy Grievance Procedure for Employee
16
Grievance Regulation* This field is required.7220-R Employee Grievance
17
Discrimination, Harassment, and Bullying Complaint Procedure* This field is required.1720/4015/7225 Discrimination, Harassment, and Bullying Complaint Procedure
18
Prohibition Against Discrimination, Harassment, and Bullying* This field is required.1710/4021/7230 Prohibition Against Discrimination, Harassment, and Bullying
Should be Empty: