Workplace Grievance & Incident Statement Form

I understand that this form is for reporting workplace grievances and incidents. I agree to provide truthful and accurate information to the best of my knowledge.

I acknowledge that I have read and understood the confidentiality and anti-retaliation policy statement above.

Your Full Name

Employee / Contractor ID (if applicable)

Your Job Title / Position

Department / Team

Direct Supervisor / Manager Name

Primary Contact Email Address

Primary Contact Phone Number

Are you reporting this incident on behalf of yourself or another individual?

If reporting on behalf of another person, please provide their name, relationship to you, and the reason you are filing on their behalf. Confirm you have their consent if applicable.

Your Employment Status

Date your employment ended

Primary Category of Grievance / Incident

If Harassment, please specify the type(s) (select all that apply):

If Discrimination, please specify the basis (select all that apply):

If Bullying / Intimidation, please specify the form(s):

If Ethical Misconduct / Fraud, please specify the nature:

Please describe the category of your grievance in detail:

Date and Time of Incident (if single event)

If the incident occurred over a period, please specify the start date:

And the end date (or approximate last occurrence):

Location of Incident (be as specific as possible)

Is this an ongoing issue?

Please provide a detailed description of the incident or grievance. Include what happened, how it happened, and the context. Be as specific and factual as possible, including direct quotes if relevant.

Rate the severity of this incident from your perspective (1 = Minor, 5 = Extremely Severe)

Has this specific incident been reported previously within the organization?

Please provide details: When was it reported? To whom? What was the outcome or response?

Were there any prior related incidents involving the same parties or issues?

Describe the prior incidents and any actions taken.

List of Involved Parties

Were there any witnesses to the incident(s)?

Witness Details

What types of evidence or documentation do you have to support your statement? (Select all that apply)

Please upload any relevant evidence files here. You may upload documents, images, audio, or video files. Ensure uploads comply with company policy and applicable laws.

Is there any physical evidence (e.g., objects, damaged property) that needs to be preserved?

Please describe the physical evidence and its location:

Do you have a timeline or chronology of events documented?

Please upload your timeline document if available:

Have you discussed this matter directly with the individual(s) involved?

Describe the outcome of your discussion:

Have you reported this issue to your direct supervisor or manager?

When did you report it and what was their response or action taken?

Please explain why you have not reported to your direct supervisor (e.g., they are involved in the incident, fear of retaliation, previous unsuccessful reports):

Have you sought advice or support from any other departments or external bodies (e.g., HR, Legal, Union, Ombudsman)?

Details of Contact with Other Bodies

How has this incident impacted you? (Select all that apply)

Please describe the specific impact this incident has had on your work life, personal well-being, and professional relationships.

Have you experienced any form of retaliation after reporting or confronting this issue?

Describe the retaliatory actions in detail, including dates, individuals involved, and any evidence:

Rate the impact of this incident on the following aspects of your work life:

What type of resolution or action would you prefer? (Select all that apply)

Please elaborate on your expectations for resolution or any specific actions you believe would be appropriate:

Are you open to participating in a mediation process if deemed appropriate by the investigator?

Preferred Method of Follow-up Communication

Best Times to Contact You (e.g., weekdays after 2 PM)

May we contact you during non-work hours if necessary?

Do you have a support person (e.g., colleague, union representative, counselor) you would like to be present during any meetings?

Support Person's Name and Contact Information:

Is there any other information, context, or details that you believe are important for us to know to fully understand this situation?

I hereby confirm that the information provided in this form is true, accurate, and complete to the best of my knowledge and belief. I understand that providing false or misleading information may result in disciplinary action.

I understand that by submitting this form, I am initiating a formal process that may involve an investigation. I consent to the organization using the information provided for this purpose and contacting relevant parties as part of the investigation.

I acknowledge that I have been informed of and understand my rights and responsibilities in the grievance process. I agree to cooperate with the investigation and maintain confidentiality regarding the investigation details to the extent possible and as required by policy.

Your Signature