Employee Complaint Form

Filer's Name

Who will be filing this complaint against an employee?

Name of Filer

First

Last

Filer's Phone Number

Enter the Phone Number of the person filing this complaint form.

Phone Number

Filer's Address

Enter the address of the person filing this complaint form.

Address

Street Address

Address Line 2

City

State

ZIP Code

Employee

Who is the employee that will be subject of this complaint form?

Name

First

Last

Employee's Title

What Title or Position does the employee hold with the company?

Title

Employee's Phone Number

Enter the employee's phone number, if unknown leave blank.

Phone Number

Company Name

What Company does the employee work for?

Company Name

Company Address

Enter the Company's Address

Company Address

Street Address

Address Line 2

City

State

ZIP Code

Date & Time of Incident

Select the Date and the Time in which the incident occured.

Date of Incident

Time of Incident

Location of Incident

Where did the Incident take place?

Location of Incident

Please specify with detail.

Description of Incident

Give a detailed description of the incident that took place.

Description

Use complete sentences when describing the incident.

Witnesses

Were there others who have witnessed the incident?

Were there others who have witnessed the incident? YesNo

Enter the Name(s) and Phone Number(s) of all Witnesses

Previous Incidents

Have there ever been previous incidents or concerns about the employee?

Have there ever been previous incidents or concerns about the employee? YesNo

Description of Previous Incident(s)/Concern(s)

Use detailed complete sentences.

Resolution

Do you have any suggestions for resolving the complaint?

Do you have any suggestions for resolving the complaint? YesNo

Suggestion for Resolution

Give suggestion(s) using detailed complete sentences.

Additional Information

Would you like to add any additional information?

Would you like to add any additional information? YesNo

Additional Information

Add any additional information using complete sentences.

Signature

eSign this document electronically or leave blank to sign by hand.

Filer's Signature

Clear

Please draw your signature.

Please write your signature to the area above.

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