Generic Employee Complaint Form

HR Policy Manual Effective 5/1/2005

EMPLOYEE COMPLAINT FORM

Name: ____________________________________ Employee I.D. Number: ___________________

Dept.: ______________ Supervisor: _______________________ Position:_______________________

The reason for my complaint is as follows: _________________________________________________

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Dates on or during which problem has occurred:_____________________________________________

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I have discussed this problem with my supervisor: Yes _______ No_____ . If “yes”,

dates

discussed and what was told to supervisor: _________________________________________________

____________________________________________________________________________________

If “no”, the reason not discussed is: _______________________________________________________

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Efforts I have made to resolve this problem are as follows:_____________________________________

____________________________________________________________________________________

The following individuals are involved or may have additional information: _______________________

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Desired resolution: ____________________________________________________________________

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____________________________________________________________ _____________________

Employee’s Signature Date

Fillable Printable Generic Employee Complaint Form