Anonymous Grievance Report Form

This form is used to report a complaint/grievance to Employnet.

You can remain anonymous and do not need to disclose your identity to complete this form. However, you may voluntarily choose to disclose your name if you wish to do so.

Name (Leave blank if you want to remain anonymous)

Department

Supervisor

The reason for my grievance is as follows (please be specific)

Date on or during which the issue has occurred:

I discussed this issue with my supervisor or my Employnet representative.

Yes No

If “Yes,” on date

If “Yes,” what was told and discussed with the Supervisor or my Employnet Representative:

If “No”, what was the reason it was not discussed

What specific action(s) or inaction(s) occurred to cause this grievance?
(Please provide specifics such as names, dates, and any other information needed to explain the grievance.)

The following individuals are involved, or may have additional information

Please list and/or attach any additional documentation you would like to include

Desired Resolution

Though not required to do so, what efforts have you made to resolve this grievance?

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