1. NAME: _________________________________________________________________
2. POSITION/DEPT:__________________________________________________________
3. PLEASE STATE DATE OF THE EVENT, OR SERIES OF EVENTS, CAUSING THE COMPLAINT:
________________________________________________________________________
________________________________________________________________________
4. PLEASE STATE YOUR COMPLAINT, INCLUDING RELEVANT AND SPECIFIC SUPPORTING FACTS, INCLUDING HOW YOU BELIEVE THE ACTION(S) YOU ARE COMPLAINING ABOUT WAS/IS HARMFUL TO YOU:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
5. PLEASE STATE THE SPECIFIC REMEDY YOU ARE SEEKING; INCLUDING A REQUEST FOR WHAT YOU WANT TO HAPPEN:
________________________________________________________________________
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Any employee who wishes to file a complaint must fill out this form completely and submit it in accordance with Level One and Two instructions in DGBA. All complaints will be processed in accordance with DGBA.
Adopted: 6/29/81
Amended: 9/27/91, 11/13/92, 8/1/97, 5/28/03
Reviewed: 3/25/94
DGBA-E - 1 of 1