Employment Complaint Adjudication Form
Please complete this form to submit a workplace complaint for adjudication. All information provided will be used solely for the resolution process.
Your Full Name
*
First Name
Last Name
Your Email Address
*
example@example.com
Your Department or Team
*
Who is the complaint against?
*
Type of Complaint
*
Please Select
Harassment
Discrimination
Unfair Treatment
Retaliation
Other
Date(s) of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Describe the incident in detail
*
Were there any witnesses?
*
Yes
No
If yes, please list witnesses (names and contact info)
Have you taken any prior action regarding this complaint?
*
Yes
No
Submit Complaint
Should be Empty: