Worker Complaint Analysis Form
Please complete all relevant sections to help us analyze and address your workplace complaint efficiently.
Complainant Name
*
First Name
Last Name
Department or Work Area
*
Date and Time of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Complaint Category (Select all that apply)
*
Harassment
Discrimination
Workplace Safety
Unfair Treatment
Wage or Hours Issue
Other
Severity/Urgency of Complaint
*
Not urgent
1
2
3
4
Extremely urgent
5
1 is Not urgent, 5 is Extremely urgent
Who or What is Involved?
*
Describe What Happened
*
Immediate Action Taken (if any)
Desired Resolution or Follow-Up
Additional Notes or Evidence Reference (links, filenames, etc.)
Submit Complaint
Should be Empty: