Use this form to confidentially report workplace grievances, incidents, or concerns.
Submissions go directly to HR, Compliance, or designated investigators for review. Your information is kept strictly confidential and shared only with those required to investigate and resolve the issue. Retaliation against anyone reporting in good faith is strictly prohibited.
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?
Your Employment Status
Full-time Employee
Part-time Employee
Contractor / Consultant
Intern
Volunteer
Former Employee
Other:
Primary Category of Grievance / Incident
Workplace Harassment
Discrimination
Bullying / Intimidation
Health & Safety Violation
Ethical Misconduct / Fraud
Violation of Company Policy
Workplace Violence / Threat
Unfair Treatment/Bias
Wage / Hour Dispute
Retaliation
Other:
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?
Were there any prior related incidents involving the same parties or issues?
Please provide information about all individuals involved in the incident. This includes the primary subject(s) of the grievance (the 'Respondent(s)'), any other individuals who were involved, and your own role if you were a participant.
List of Involved Parties
Full Name | Job Title / Position | Department | Role in Incident | Contact Information (if known) | |
|---|---|---|---|---|---|
Were there any witnesses to the incident(s)?
What types of evidence or documentation do you have to support your statement? (Select all that apply)
Emails
Text Messages / SMS
Instant Messages (e.g., Slack, Teams)
Photographs
Videos
Audio Recordings
Written Documents / Notes
Medical Records
Performance Reviews
Witness Statements
No evidence available currently
Other:
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?
Do you have a timeline or chronology of events documented?
Have you discussed this matter directly with the individual(s) involved?
Have you reported this issue to your direct supervisor or manager?
Have you sought advice or support from any other departments or external bodies (e.g., HR, Legal, Union, Ombudsman)?
How has this incident impacted you? (Select all that apply)
Emotional distress (e.g., anxiety, depression)
Physical health issues
Decreased job performance or productivity
Difficulty concentrating on work
Fear for personal safety
Damage to professional reputation
Strained workplace relationships
Consideration of leaving the organization
Required medical or psychological treatment
Negative impact on career progression
No significant impact
Other
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?
Rate the impact of this incident on the following aspects of your work life:
No Impact | Minimal Impact | Moderate Impact | Significant Impact | Severe Impact | |
|---|---|---|---|---|---|
Overall job satisfaction | |||||
Ability to perform daily tasks | |||||
Sense of safety in the workplace | |||||
Trust in management | |||||
Mental and emotional well-being |
While the organization will determine appropriate actions based on investigation findings, understanding your perspective on resolution can be helpful. Please note that specific outcomes cannot be guaranteed.
What type of resolution or action would you prefer? (Select all that apply)
Formal investigation by HR or Compliance
Mediation or facilitated discussion
Coaching or training for the involved party
Disciplinary action against the respondent(s)
Policy change or clarification
Restorative justice practices
Apology from the respondent(s)
Transfer to a different team or department
Implementation of stronger oversight
No specific action, just documentation
Other
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
Phone Call
In-person Meeting
Secure Messaging Platform
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?
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