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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:
Title:
Campus Address:
Phone Number where you can be reached:
Complaint/Concern Information
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.