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Sample Formal Complaint Form

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.

Sample Employer Formal Harassment Complaint Form

Complainant Information

Name:

Contact Information:

Work Unit:

Job Title:

Supervisor’s Name:

Contact Information:

Witness Information

List names of possible witnesses:

Name:

Position:

Contact Information:

Information about the individual(s) you feel has/have harassed you:

Name of person(s) against whom this complaint is made:

Date of incident:

In your opinion is the harassment based on any of the following? Check all that apply to your situation.

___ Sexual Orientation

___ Religion

___ Sex

___ Nationality

___ Disability

___ Age

___ Place of Origin

___ Family Status

___ Creed

___ Colour

___ PhysicalWeight/Height

___ Race

If not based on any of the above grounds, is the harassment based on either of the following:

a) Repeated incidents that have caused you to be humiliated or intimidated. Yes___ No____

-OR-

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.)

Declaration

Signature: ______________________________ Date: ______________

I acknowledge receipt of this complaint.

Supervisor’s Signature: ____________________ Date: _______________

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The Shift Project is funded by the Department of Justice and delivered by the Public Legal Education Association of Saskatchewan (PLEA).