The company encourages you to resolve any problem or issue informally with the individuals involved. However, if you have a concern or experience a problem that affects you or your co-workers, we ask that you complete this form and return it to Human Resources within five working days after the incident or problem occurred. The company will then provide you with a written response to your issue.
Employee Information
Name of Employee claiming incident: _________________________________
Employee's Job Title: _____________________________________________
Incident Information
Date/Time of Incident:________________________________________________________
Location of Incident:________________________________________________________
Description of Incident:
Witnesses to Incident:________________________________________________________
In your opinion, was this problem / incident in violation of a company policy? Yes No
If yes, specify which policy and how the incident violated it.
What ideas do you have for remedying the situation?
Is there any other information you feel is relevant to this situation?
Signature of person preparing report: ______________________________________________________________
Date: __________________________________________________________
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