Fillable COMPLAINT/GRIEVANCE FORM

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COMPLAINT/GRIEVANCE FORM

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COMPLAINT/GRIEVANCE FORM
DEPARTMENT OF HUMAN RESOURCES & PAYROLL SERVICES
3100 CLEBURNE AVENUE ▪ HOUSTON, TEXAS 77004
Phone (713)313-7521/ Fax (713)313-4347
About You (“The Complainant”)
1. Your name and T-number: __________________________
2. Status: Student [ ] Staff [ ] Faculty [ ] Other (specify):
3. Administrative Unit/Department and title:
(If applicable)
4. Mailing Address: _____________________________________________ ______
5. Phone Number: ___________ 6. E Mail Address: _____________________________
About The Person(s) You are Filing a Complaint Against (The “Respondent”)
7. Respondent Name: ___________________________________________________________________
8. Status: Student [ ] Staff [ ] Faculty [ ] Other (specify):
9. Administrative Unit/Department and title:
(If applicable)
About Your Complaint
10. Dates and frequency the event(s) occurred: ______________________________________________
11. Please describe the specific decision(s) or circumstances causing the complaint (give specific factual
details). If additional space is needed, you may write on the reverse side of this form or attach a separate
sheet(s):
______
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12. Please explain how you have been harmed by this decision or circumstance:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
13. Please list the MAPP allegedly violated, misinterpreted, or misapplied.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
14. Please describe any efforts you have made to resolve your complaint informally and the responses to
your efforts:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
With whom did you communicate? ________________________________________________________
On what dates(s)? ______________________________________________________________________
15. Are there others who have witnessed this behavior or others who have experienced similar behavior
by the individual named above? If so, please provide their name(s), indicate if they are a witness or an
individual with similar experience, their address(s) and their phone number(s).
FOR OFFICE USE ONLY
Date/Time Received:
Case No:
June 2019
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16. Please describe the outcome or remedy you seek for this complaint:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
17. Have you filed this report with any other agency or an attorney? Yes [ ] No [ ]
If yes, with whom?
18. Do you have any suggestion for proposed action to address or resolve the complaint/grievance?
19. Do you have any additional information and comments (use separate sheet if necessary):
Signature of person making report: Date:
Please return the completed form to the Department of Human Resources, Hannah Hall, Suite 126
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COMPLAINTGRIEVANCE FORM

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Completed 25 May 2022

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