Fillable Printable Noncomplete Employee Complaint Form

Noncomplete Employee Complaint Form

EMPLOYEE COMPLAINT FORM

Nationwide Medical Staffing, Inc. takes employee complaints of discrimination, harassment,

unethical or unfair conduct as serious matters. So that we may properly investigate your

concern, you are requested to fill out this form as completely as possible. Please use additional

sheets of paper where needed. After a prompt and thorough investigation into your complaint,

you will be notified of the company’s intended action. Should you have any questions about the

process, please set them forth at the end of this form and we’ll do our best to answer them.

Thank you.

Employee Name: Title:

Department: Supervisor Name:

1. Please describe in as much detail as possible the nature of your complaint. Please provide

or identify all known persons, documents and witnesses to your concerns:

2. Please describe how the actions you complain about have affected your ability to perform

your job:

3. Please describe any positive solutions you believe can help resolve your complaint:

4. Please provide any additional comments you wish the company to consider when

investigating your complaint:

I declare that the facts set forth in this complaint form are true and accurate pursuant to the

penalty of perjury under the laws of this State.

Employee signature: Date: