Employee Complaint Form

Date of Complaint:

Name:

Department:

Job Title:

Date of Incident:

Nature of complaint:
Please describe in detail the nature of your complaint, including any relevant dates, times, and locations:

Persons Involved:
Please provide the names and job titles of any individuals involved in the incident:

Witnesses:
Please provide the names and job titles of any witnesses to the incident:

Notes:

Supporting Documentation:
Please attach any supporting documentation such as emails, memos etc

Desired outcome:
What outcome are you seeking as a result of filing this complaint?

Acknowledgment: by signing below, I acknowledge that I have read and understand the employee complaint form, and I certify that the information provided is true and accurate to the best of my knowledge:

Put signature below,

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