Employee Complaint Form

Information you will need

• What’s the employee's department?
• What’s the employee's title?
• What's the employee's work ID number?
• What’s the employee's phone number?
• What's the employee's email?
• What’s the employee’s mailing address?
• When did the incident occur?
• What time did the incident occur?
• Where did the incident occur?
• What are the details of the incident resulting in this complaint form?
• What's the first witness's name?
• What's the first witness's phone number?
• What's the second witness's name?
• What's the second witness's phone number?
• What's the third witness's name?
• What's the third witness's phone number?
• Has the employee raised these concerns before?
• Who was the issue discussed with?
• On what date was the issue previously discussed?
• What was the outcome of the discussion?
• What's the employee's desired outcome?
• Does the employee have any additional information to add?
• What’s the name of the employee?
• Who is receiving this complaint form?

Completed by the employee.

The form includes a notary acknowledgment, a witness section.