Sample Formal Complaint Form

Even though it may differ in your workplace this sample can help you understand the type of information needed for a formal complaint.

Name:

Contact Information:

Work Unit:

Job Title:

Supervisor’s Name:

Contact Information:

List names of possible witnesses:

Name:

Position:

Contact Information:

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

Date of incident:

___ Sexual Orientation

___ Religion

___ Sex

___ Nationality

___ Disability

___ Age

___ Place of Origin

___ Family Status

___ Creed

___ Colour

___ PhysicalWeight/Height

___ Race

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.)

Signature: ______________________________ Date: ______________

I acknowledge receipt of this complaint.

Supervisor’s Signature: ____________________ Date: _______________