Employee Concern Form

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Instructions:

Please answer as clearly and in as much detail as possible.
All information will be treated confidentially.
If a question does not apply, please write “N/A.”

Name *

First

Last

Store # *

Complaint Types: *

Harassment (general)
Sexual harassment
Verbal abuse or insults
Physical intimidation or threats
Bullying or psychological mistreatment
Discrimination
Abuse of authority or power
Retaliation after reporting a concern or complaint
Unfair treatment or favoritism
Hostile or unsafe work environment
Inappropriate comments or behavior
Violation of privacy or confidentiality
Other

Description of the Situation *

Please describe in detail the incidents you consider to be harassment or mistreatment.

When and where did these incidents occur? (Dates, times, locations) *

Were there any witnesses to these incidents? *

If so, please provide their names and positions. *

Please explain the nature of the harassment? *

Have you ever had a personal or romantic relationship with the person involved in this complaint? If so, please describe the nature and duration of that relationship. Do you believe the harassment or mistreatment is related to your decision not to have or to end a personal or romantic relationship with this person?

Have you experienced any negative actions at work (such as shift changes, reduction of responsibilities, unfair criticism) after rejecting personal advances? *

Do you have any evidence to support your complaint? (messages, emails, recordings, witnesses). If so, please attach or upload the supporting documents or files here.

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Any additional comments you consider relevant to understanding the situation?