Complaint Form

REPORT / COMPLAINT FORM

Confidential – For Internal Use Only

Please complete this form if you have experienced or witnessed any form of harassment, discrimination, or inappropriate conduct. The information you provide will help us respond appropriately and take any necessary steps to ensure a safe and respectful environment.

Report Discrimination or Harassment Form

Employee Full Name

Phone Number

Job Title

Zone Area

Type of Complaint (check all that apply)

Sexual Harassment Discrimination (Race/Color, Gender/Gender Identity, Sexual Orientation, Religion, National Origin, Disability / Accessibility, Age, etc.) Misconduct or Unprofessional Behavior

Description of the Incident

Description Checklist (check off what you've included in your description above)

Person(s) involved (accused) Dates and Times of incidents Locations Names of any Witnesses How frequent this behavior is ongoing

Have You Taken Any Steps to Resolve This Issue?

Supporting Evidence (emails, messages, photos, medical notes or documentation, screenshots, witness statements etc.)

Requested Action or Resolution (What would you like to see happen as a result of this complaint?)

Investigation Mediation or facilitated conversation No-contact directive Training or education Disciplinary action (if warranted) No specific outcome – just want to report

Employee Acknowledgement

I affirm that the information provided above is accurate and truthful to the best of my knowledge. I understand this complaint will be treated as confidential to the extent possible, with the need to investigate and take appropriate action.

Todays Date

*For HR or Intake Use Only

Next Steps

Thank you for your submission.
We appreciate you taking the time to share your concerns. Our team will review the details carefully and follow up with you for clarification or updates if needed.

If this is urgent or you have additional information to share, please don’t hesitate to reach out directly at staffing@greeneventninjas.com or (315) 501-6909.

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