Employee Complaint Form

Create Document

Employee Complaint Form

An employee complaint form allows an employee to notify their supervisor of a workplace issue. It is typically used to report harassment, discrimination, or other employee rights violations. The form should list witnesses and provide enough detail to allow the issue to be investigated fully.

Create Document
PDF
Word
ODT

Last updated August 7th, 2025

Document Preview

An employee complaint form allows an employee to notify their supervisor of a workplace issue. It is typically used to report harassment, discrimination, or other employee rights violations. The form should list witnesses and provide enough detail to allow the issue to be investigated fully.

Downloads: 21
  1. Home »
  2. Employee Forms »
  3. Write Up »
  4. Complaint

Workplace Retaliation Laws

Federal law prohibits employers from retaliating against employees who make complaints related to:[1]​

  • Discrimination against sex, religion, race, or age[2]​
  • Unsafe conditions[3]​
  • Failure to reasonably accommodate a disability[4]​
  • Violation of protected rights (e.g., taking maternity leave)[5]​

That said, some federal protections only apply when the employer has over a certain number of employees (15-50, depending on the category of protected right). There are often additional and more stringent worker protection laws at the state level that cover employees working for smaller employers, though this isn’t always the case.[6]​

Handling Workplace Complaints

  1. Gather complaint form. Employee submits a written complaint to their supervisor or the company’s HR department.
  2. Investigate complaint. The supervisor or HR discusses the issue with the employee and promptly begin a formal investigation.
  3. Collect information. During the investigation, HR rep or supervisor gathers information from the parties involved including any witnesses.
  4. Deliver response. Once the investigation is complete, the involved parties are notified of the outcome and of any corrective action that will be taken.

Sample

Download: PDF, MS Word, ODT

EMPLOYEE COMPLAINT FORM

EMPLOYEE INFORMATION

Employee Name: [EMPLOYEE NAME] Employee Department: [EMPLOYEE DEPARTMENT]
Employee Title: [EMPLOYEE TITLE]  Employee ID #: [EMPLOYEE ID #]
Supervisor Name: [SUPERVISOR NAME]  Email: [EMPLOYEE EMAIL]
Address (for mailed correspondence): [EMPLOYEE ADDRESS]

COMPLAINT INFORMATION

Date of Incident: [MM/DD/YYYY] Time of Incident: [MM/DD/YYYY]
Location of Incident: [INCIDENT LOCATION]

Describe the incident in detail: (attach additional sheets or documents if needed) [INCIDENT DETAILS]

If there are any witnesses, provide their information below:
1) Witness Name: [WITNESS NAME] Phone Number: [WITNESS PHONE]
2) Witness Name: [WITNESS NAME] Phone Number: [WITNESS PHONE]
3) Witness Name: [WITNESS NAME] Phone Number: [WITNESS PHONE]
Is this the first time raising these concerns? ☐ Yes ☐ No
If no, who were they discussed with? [INDIVIDUAL NAME] Date: [MM/DD/YYYY]
What was the outcome of the discussion? [DISCUSSION OUTCOME]

EMPLOYEE COMMENTS

If you have a desired outcome or any suggestions to remedy the complaint, describe them here:
[DESIRED OUTCOME]

Is there anything else relating to the complaint that you’d like to add?
[ADDITIONAL DETAILS]

ACKNOWLEDGMENT

By signing below, I acknowledge that the information provided in this complaint form is true and accurate to the best of my knowledge. I understand that this form will be used for the purpose of investigating my complaint.

Employee Signature:                                                               Date: ______________
Print Name:[EMPLOYEE NAME]
Received By:                                                               Date: ______________
Print Name:[INDIVIDUAL NAME]

Sources

  1. 42 U.S.C. § 2000e(b), 29 U.S.C. § 2611(4)(A)(i)
  2. 42 U.S.C. § 2000e-2(a)(1), 29 U.S.C. § 621(b), 42 U.S.C § 2000e-3(a), 29 U.S.C § 623(a)
  3. 29 U.S.C § 660(c)(1), 29 U.S.C § 654(a)
  4. 42 U.S.C. § 12112(5)(A), 42 U.S.C § 12203(a)
  5. 29 U.S.C § 2615(a)(2). 29 U.S.C § 2612(a)(1)(A)
  6. Cal. Lab. Code §§ 98.6(a), Or. Rev. Stat. §§ 659A.199(1)