401.05E1 - Employee Complaint Form

Date of complaint:                                                    ________________________________________________________________

Name of Complainant:                                             ________________________________________________________________

Are you filling out this form for yourself
or someone else (please identify the
individual if you are submitting on behalf
of someone else)                                                     ________________________________________________________________
                                                                                         ________________________________________________________________

Who or what entity is this complaint
against?                                                                    ________________________________________________________________

Date and place of alleged incident(s):           ________________________________________________________________
                                                                                       ________________________________________________________________
                                                                                       ________________________________________________________________

Name of any witnesses (if any):                          ________________________________________________________________

In the space below, please describe what happened.  Please be as specific as possible and attach additional pages if necessary.

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I agree that all of the information on this form is accurate and true to the best of my knowledge.

 

Signature:  ________________________________________  Date:  ____________________________________