EMPLOYEE COMPLAINT/CONCERN FORM

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the 1500s
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Details
Detail sofothe Employee:
f th e E mp lo yee :

Your
Your name: Date:
name: ___________________________________________Date:___________________________________
Status:
Status: Staff
StaffFaculty
FacultyOther
Other(specify): Management
(specify): ____________________________________________ Management
Center/Department:
Center/Department: _____________________________________________________________________ Title:
Title:
______________________________________________________________________________________ Campus
Campus
Address:
Address:_____________________________________________________Phone
PhoneNumber
Numberwhere
whereyou
youcan
canbebe
reached:
reached: _______________________________________

Complaint/Concern Information:
C ompl aint/C on cern Inf o rma tio n :

Date
Date of
of Incident:
Incident: ___________________________ Time
Timeof
ofIncident:
Incident: _________________________________
Location
Locationof Incident: ___________________________________________________________________ please
ofIncident:
describe
describethe
thespecific
specificact(s):
act(s):

thereothers
Are there otherswho
who have
have witnessed
witnessed thisthis behavior
behavior or others
or others whoexperienced
who have have experienced
a similaraconcern
similar
or problem? If so, please provide their name(s) and phone numbers.
concern or problem? If so, please provide their name(s) and phone numbers.

Do you have
have any
anysuggestion
suggestionfor
forproposed
proposedaction
actiontoto address
address or or resolve
resolve thethe complaint/concern?
complaint/concern?

Do
Do you
you have
haveany
anyadditional
additionalinformation oror
information comments?
comments?