EMPLOYEE COMPLAINT(S) REPORT FORM
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Employee Name: ……………………………………………..
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Employee Position & Department: ………………………………………………………………….
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Supervisor/Manager: ………………………………………………………………….
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Complaint Details: ………………………………………………………………………………
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1. Nature of Complaint:
[ ] Harassment
[ ] Discrimination
[ ] Retaliation
[ ] Bullying
[ ] Non-payment or delayed salary
[ ] Health and Safety Concerns
[ ] Unreasonable work Expectations or Overworking
[ ] Unfair Treatment
[ ] Hostile Work Environment
[ ] Other (Specify):
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2. Date(s) of Incident(s): ………………………………………………………………..…………….
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3. Time(s) of Incident(s): …………………………………………………………………………..
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4. Location(s) of Incident(s): ………………………………………………………………………………
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5. Description of Complaint [Provide a detailed description of the complaint, including the names of any individuals
involved, witnesses, and any relevant details]:
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6. Have you reported this complaint to anyone else within the company?
[ ] Yes (Please provide details below)
[ ] No
If yes, please provide details:
Name of Person Reported To:
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Date of Report:
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Actions Taken (if any):
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7. Do you have any supporting documentation or evidence related to this complaint? [ ]
[ ] Yes (Please attach)
[ ] No
If yes, please attach any relevant documents or evidence.
8. Have you experienced any retaliation for reporting this complaint?
[ ] Yes
[ ] No
If yes, please describe the retaliation [Provide details of any retaliation, if applicable]:
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9. Preferred Resolution [Describe what you believe would be a fair resolution to this complaint]:
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10. Additional Comments [Include any additional comments or information you think is important]:
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Employee's Signature:
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HR/Management Use Only:
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Date Received: ……………………………………………………………………
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