Fillable Grievancecomplaint Initiating a Grievance Complaint

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Grievancecomplaint Initiating a Grievance Complaint

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This part to be filled out by complainant
Initiating a Grievance Complaint
(Additional plain paper may be used as necessary and stapled to this form.)
Name of complainant: ______________________________________ Date: ___________
Complainant’s disability(ies):_____________________________________________________________
Description of the issue:_________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Date(s) of incident(s): ___________________________________________________________________
Details of what occurred or continues to occur: _______________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Names and contact information for witnesses who have direct knowledge related to this complaint:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Signature of complainant Date of signature
This part to be filled out by investigator
Name of person investigating: _____________________________________ Date of report: __________
Findings: _____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Signature of investigator Date of signature
08/14
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Grievancecomplaint Initiating a Grievance Complaint

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Completed 15 February 2020

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