Preview Hr Grievance

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HR$500! ! 7/2013!

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HIAWATHA!HOMECARE!

GRIEVANCE!REPORT!

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The!purpose!of!this!form!is!to!provide!a!mechanism!to!encourage!reporting!of!any!action!or!suspected!action!

taken!within!Hiawatha!HomeCare!that!is!illegal,!fraudulent,!and!unethical!or!in!violation!of!any!adopted!policy!

of!the!company.!Anyone!reporting!a!violation!must!act!in!good!faith,!without!malice!to!Hiawatha!HomeCare!or!

any!individual,!and!have!reasonable!grounds!for!believing!that!a!violation!occurred.!!

NO#ONE#WHO#IN#GOOD#FAITH#MAKES#A#REPORT#SHALL#SUFFER#RETALIATION.#

Complaints!and!their!investigation!will!be!kept!confidential!to!the!extent!possible,!consistent!with!the!need!to!

conduct!an!adequate!investigation,!to!comply!with!all!applicable!laws,!and!to!cooperate!with!law!enforcement!

authorities.!

You!are#not#required!to!provide!your!name!and!may!retain!anonymity.!If!you!choose!to!provide!your!name,!it!

will!remain!confidential!whenever!possible.!Anyone!filing!an!anonymous!report!will!not!be!updated!as!to!the!

progress!of!the!investigation.!Making!a!complaint!does!not!automatically!shield!you!from!consequences!of!

your!own!involvement!in!unlawful!or!improper!conduct.

Please#provide#as#much#detail#as#possible#to#enable#a#thorough#investigation#of#the#matter.!

What happened? Who was involved? What date did the event occur? Where did the event occur? If you need more

space, please attach additional pages. Please make a note if additional papers are attached.

_________________________________________________________________________________________________

OPTIONAL:#

Name:!_____________________________!(Please!Print)!

Employee!Signature:!________________________________!!!!!!Date:!_____________!

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