Employee Complaint Form

Use this from to file an employee complaint.

Reporting Party

Employee ID*

Employee Name*

Email Address*

Facility*

Work Phone*

Please provide the best phone number to contact you at work.

Phone

Work Contacts

It may be necessary to contact you at work. Please check here if you do not want messages left with members of your chain of command concerning this complaint.

Incident Detail

Please provide as much information as possible concerning your complaint.

Is your complaint related to your status in a protected class?*

Yes

Date of Incident*

When did the alleged incident occur? If the actual incident date is unknown, please provide an approximate date.

Location of Incident*

Please describe the location of the alleged incident.

Incident Description*

REASON FOR COMPLAINT (Be specific as to the reason you are filing this complaint; include specific facts, names, dates, places, etc., to include facility/party against whom the complaint is being filed. You may upload additional sheets in the "File Upload" section at the bottom of this form if necessary):

Does this situation or conflict interfere with your ability to complete your job duties?*

Yes

Describe Adversity and/or Interference(s)*

Please provide a brief narrative of how the reported situation has adversely affected you or your ability to complete your job duties.

Witnesses

Please list all witnesses.

Were any inmates involved in the alleged incident?*

Yes

Involved Inmate Names and DOC Numbers

If so please list names and DOC numbers.

Describe Inmate Involvement

Please describe any inmate involvement in the alleged incident.

Actions Taken

What steps or actions have been taken to resolve this conflict

Have you attempted to resolve this issue through your supervisor or chain of command?*

Yes

Date of Supervisor Meeting

If you have attempted to resolve this issue and have participated in a resolution meeting with your supervisor and/or your supervisor's supervisor, please provide the date of this meeting.

Meeting Attendees

Please provide the name and titles of all meeting attendees.

Meeting Detail

Briefly describe actions taken with your supervisor to resolve this issue.

Have you attempted any other methods of resolving this issue?*

Yes

Describe Other Actions Taken to Resolve*

Remedy Sought

What would you consider to be an ideal resolution for your situation?

What remedy are you seeking?

Briefly state the remedy or relief you are seeking from this issue.

Documents and Additional Comments

Please provide any documentation or additional information you feel is pertinent to your complaint.

File Upload

Please upload any supporting documentation.

Drag and drop files here or

Additional Comments

Send me a copy of my responses

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