Employee Complaint and Incident Reporting

First and Last Name*

Please provide your email if you would like direct follow up on this item

Department*

Select

Supervisor*

Do you want to report an Incident or a Complaint? (see definitions below)*

An incident is a specific event or circumstance where you have experienced a negative impact on your health, safety, or wellbeing. This resource can be used if you experience an incident or witness an incident that you believe should be reported and addressed by Noorda-COM administration (i.e., concerning behavior or discrimination).

Complaints can be related to various issues, such as inappropriate or unprofessional conduct, safety concerns, organizational policies or decisions, interpersonal conflicts, etc. By submitting this complaint you are seeking resolution to an issue or for better treatment and fairness, after efforts to resolve the matter have not achieved acceptable results. Use this form to express dissatisfaction with a situation, decision, or action.

Complaint

Incident

Complaint submissions will be sent to Human Resources for further review and processing.

Location of Incident*

Date of Incident*

Time of Incident*

Who was Involved in the Incident?*

Personal Injury Clarification*

Work Related

Not Work Related

Work Related Personal Injury

Since this incident happened during work hours, please fill out the form found here. The form will also be emailed to you if you included your email above.

List details of the incident.*

List any witnesses to the incident.*

Please describe in as much detail as possible the nature of your complaint.*

Please identify all known witnesses to your concerns.*

Please describe how the actions you are complaining about have affected your ability to perform your job.*

Please describe efforts you have made to resolve the issue (i.e., speaking directly to a co-worker or consulting with a supervisor).*

Please describe any solutions you believe might help resolve your complaint.*

File Upload

Please provide any additional material or comments you wish Noorda-COM leaders to consider.

Drag and drop files here or

Employee Signature*

I declare that the facts set forth in this complaint form are true and accurate.

Send me a copy of my responses

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