Employee Complaint Form

Name

Position

Agency*

Department (if applicable)

Phone Number

Name*

Position

Agency*

Department (if applicable)

Relationship to You (Supervisor, coworker, etc.)

Phone Number

Date of incident*

Type of incident*

Where did the incident occur?*

Explain the details of the incident:*

Explain your reaction to the incident:*

Describe what happened after the incident:*

Please provide the names of any witnesses if applicable

Who have you discussed this incident with if anyone?*

Identify your desired outcome of this complaint:*