forms\employee concerns and issues form 9/08
Los Rios Community College District
Employee Concerns and Issues
In line with our interest based approach to problem solving, employees should use this form to raise issues, concerns, or other items for
resolution in an informal manner. Do not use this form for matters that are a violation of state law (i.e. sexual harassment and/or
discrimination, workplace violence, formal grievances, etc.).
Name: ____________________________________________________ Date: _____________________
ARC BEDC CRC DO FLC FM SCC Other ____________________
Telephone (home): _________________________ Telephone (work): _________________________
When did the issue arise (date and time)?
Who was involved?
What was the issue(s)?
How would you like this issue resolved?
Attach additional pages as necessary.
Has this information been shared with your supervisor? Yes No
If yes, what was the outcome?
If not, you are encouraged to share with your supervisor unless he/she is one of the parties involved.
Complainant Signature: __________________________________________ Date: ______________________
Completed form should be directed to one of the following: Appropriate Associate Vice President, Appropriate Vice President, College Equity
Officer, or Human Resources.