Employee Complaint Form

It is the policy of this agency to investigate all complaints and take appropriate action. If you wish to file a written complaint that has not been addressed through a preliminary discussion with your supervisor, please complete this form to document your complaint, then submit to (department/ supervisor/manager/director—agency should specify) personnel.

The person(s) involved in this complaint are: *

Details of the Complaint *

Please include an accurate description of all relevant dates, places, events, etc. pertaining to the complaint.

It may become necessary to disclose your identity and/or complaint to conduct a formal investigation. Should such disclosure become necessary, it will be only to the person(s) with a need to know your identity or the details and nature of the complaint.

I acknowledge that I have read this document and understand my obligation to provide information as needed and to cooperate fully and completely with any investigation of this complaint. Should it become necessary, I authorize the agency to disclose my identity and/or details of this complaint.

Today's Date *

Full Name *

Employee Signature *

Clear