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Human Resources (Darton State College)

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Human Resources
Notice of Employee Complaint:
A grievance is a problem, concern or complaint related to Albany State University’s working
environment.
During the complaint resolution process, all parties to the matter must maintain
confidentiality.
All
documents and paperwork relating to this complaint will be stored in a secure
manner and shall only
be
directed to others associated with the matter under confidential cover.
All necessary steps will be
taken
to ensure that no unauthorized persons can access or have the
opportunity to access these
files.
Employee
Name
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Last Name First Name
Department & Job Title.
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Date incident occurred:
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Please provide detailed responses to the following questions:
1. What is the nature of your
complaint
or concern?
Please describe specific incidents relating to this
complaint
Human Resources
2. Who or what are you identifying as the cause of your complaint?
You may list more than one person or
incident.
3. When and where did the above actions or incidents take place?
Please indicate the time, part of the day and location the above indecent/ incidents
occurred.
4. How frequently have these actions or incidents occurred?
Please indicate the number of times the above
incident/incidents
took place.
5. How long did these actions or incidents continue? Are they ongoing?
Were the actions continued over a period of time or was the behavior/incident
isolated?
Human Resources
6. Witnesses
Were there any witnesses to this behavior
/incident?
7. Action taken by you.
What action did you take in relation to this
complaint?
8. Outcome
What do you consider a satisfactory outcome to be concerning this
issue
?
Additional Comments
Employee
Declaration:
I
declare that
information
provided on this document is true. I understand that there are severe
penalties
for
providing
a false or misleading statement, and that these penalties may include
termination of
employment.
I
understand that this document may be tendered, if required, in a
relevant court or commission at any
time
in the
future
.
Employee
Signature
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Witness Signature &
Name
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Date:
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Date:
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Human Resources (Darton State College)

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Completed 25 July 2020

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