Grievance Submission Form
Submit grievances online as a volunteer, employee, member, parent, guardian, or participant. All sections are required for proper review.
Is this a Volunteer or Employee, Member, Parent, Guardian or Participant grievance?
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Volunteer
Employee, Member, Parent, Guardian or Participant
Section 1: Grievance Form for Volunteers
Individual Filing Complaint (Full Name)
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First Name
Last Name
Volunteer Role
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Date of occurrence
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-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of occurrence
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Hour Minutes
AM
PM
AM/PM Option
Other Individuals Involved/Witnesses to complaint
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Type of Complaint (select all that apply)
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Inappropriate Behavior by Employees/Volunteers
Inappropriate Behavior by Consumers
Retaliation
Whistleblowing
Other
Describe the situation: What happened, where it happened, when it happened, who was involved, who was present, who was notified? If suspected abuse, was it reported to the State?
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Has this situation ever occurred previously?
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Describe the remedy you seek. Please list all remedies sought as a result of bringing this grievance. What would you like to see happen to solve this issue?
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Submitted by (Full Name)
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First Name
Last Name
Telephone number
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Please enter a valid phone number.
Format: (000) 000-0000.
Location or organization
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Signature
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Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Section 2: Employee, Members, Parent, Guardian or Participant Grievance Form
Individual Filing Grievance (Full Name)
*
First Name
Last Name
Date of occurrence
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of occurrence
*
Hour Minutes
AM
PM
AM/PM Option
Other Individuals Involved/Witnesses to Complaint
*
Type of Complaint (select all that apply)
*
Discrimination
Harassment
Unsafe Working Conditions
Retaliation
Whistleblowing
Other
Describe the situation: What happened, where it happened, when it happened, who was involved, who was present, who was notified? If suspected abuse, was it reported to the State?
*
Has this situation ever occurred previously?
*
Describe the remedy you seek. Please list all remedies sought as a result of bringing this grievance. What would you like to see happen to solve this issue?
*
Submitted by (Full Name)
*
First Name
Last Name
Telephone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Location or organization
*
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
*
example@example.com
Submit Grievance
Submit Grievance
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