Worker Grievance Submission Form
Please complete this form to report workplace concerns. Submissions will be handled confidentially.
Section 1: Personal Details
Complainant’s Full Name:
Sex:
-- Select --
Female
Male
Company Name:
Employee ID (if applicable):
Department / Worksite:
Contact_info :
Email:
Preferred Method of Contact:
-- Select --
Email
Phone
In-Person
Anonymous Submission
Section 2: Affected Person
I am submitting this complaint on behalf of:
-- Select --
Myself
Somebody else
If somebody else, affected person’s full name:
Section 3: Type of Grievance
Category: Workplace Issue
Workplace misunderstandings or conflicts
Scheduling issues or shift concerns
Lack of resources (tools, equipment, workspace)
Minor administrative concerns (payroll delays without financial harm)
Category: Labour Rights & Workplace Safety Concerns
Unfair treatment (bias in promotions, wage disparities, favoritism)
Harassment (non-sexual), such as bullying, verbal abuse, intimidation
Workplace health & safety concerns (hazardous conditions, lack of equipment)
Failure to comply with contract terms (benefits, overtime pay disputes)
Category: Legal & Ethical Violations
Sexual harassment, exploitation, or abuse
Workplace discrimination (race, gender, disability, etc.)
Forced labour, human trafficking, or exploitative working conditions
Child labour involvement or violations
Serious safety risks (negligence leading to injuries or fatalities)
Retaliation against whistleblowers
Section 4: Grievance Description :
Section 5: Desired Resolution
Direct resolution through mediation
Formal investigation and disciplinary action
Workplace improvement measures
Policy change or management intervention
Section 6: Confidentiality Preference
I wish to remain anonymous
I allow human resources or management to know my identity
I require full protection from retaliation
Section 7: Supporting Documents (Optional)
Witness statements
Photos / screenshots
Email / message records
Upload Files (Optional):
By submitting, I confirm that the information provided is accurate and submitted in good faith.
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