Employee Complaint/Concern Form
The Department of Human Resources encourages you to contact the Employee Relations Office if you
have a complaint or concern, or experience a problem that affects you or your co-workers. We ask that
you complete this form within five working days after the incident or problem first occurred. Human
Resources will contact you as soon as possible.
Your name: ___________________________________________Date:____________________________
Status: Staff Faculty Other (specify): _________________________
Management Center/Department: ________________________________________________________
Campus Address:______________________________________ ___________
Phone Number where you can be reached: _______________________________________
Date of Incident: ___________________________ Time of Incident: _______________________
Location of Incident: ________________________________________________________________
Please describe the specific act(s):
Are there others who have witnessed this behavior or others who have experienced a similar concern or
problem? If so, please provide their name(s) and phone numbers.