This is a sample formal complaint form. Your workplace may use a different form or not have a set form for making a formal complaint.
Even though it may differ in your workplace this sample can help you understand the type of information needed for a formal complaint.
List names of possible witnesses:
Name of person(s) against whom this complaint is made:
Date of incident:
___ Sexual Orientation
___ Place of Origin
___ Family Status
a) Repeated incidents that have caused you to be humiliated or intimidated. Yes___ No____
b) A single serious incident that has had a lasting harmful effect on you. Yes___ No___
In your own words, describe the conduct, comments or display you found objectionable. Give details of date and location of the incident(s) that is/are the basis of your complaint.
What type of resolution do you seek? (e.g., supervisor to direct or counsel person to correct conduct; facilitated meeting with alleged harasser; apology; workshops or training sessions; mediations; or other.)
Signature: ______________________________ Date: ______________
I acknowledge receipt of this complaint.
Supervisor’s Signature: ____________________ Date: _______________
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