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Rev. 8/2013 Page 1
CLASSIFIED EMPLOYEE COMPLAINT FORM
Definition: “A complaint is an allegation made by an employee that the employee has been adversely affected on an
employer-employee matter not covered by this Agreement.” MPCD/MPCEA 14.1.5
Directions: This form is to be completed by the employee with a complaint. “The complaint shall be brought to the
attention of the MPCEA Chapter President and Associate Dean of Human Resources.” MPCD/MPCEA 14.1.5
Name:
Last
First
MI
Work Phone:
Work Location/Dept.:
Date(s) complaint occurred:
Concise statement of the circumstances and complaint. Include names of witnesses, specific dates,
actions and any attempts to solve the situation. Attach an additional sheet of paper, if needed:
Specific Remedy Sought:
Complaint filed with Human Resources:
____________________________________________________________________________________
Signature of HR Staff Title Date