Grievance Form
Page 1
Contact Information
First Name
Last Name
Primary Phone Number
Email
I am a...
Client
Volunteer
Staff
Member of the community
As a Client I am currently in __________ stage.
Applicant
Candidate
Client
Graduate
I primarily volunteer as a
Home Handler
Puppy Nanny
Nursery Team Member
Other
Client
Date/Timeframe of Incident
Please select the type that best describes your concern:
Denial of program admission
Unfair treatment
Unresolved issue during training or placement
Involuntary termination from training
Other
Please Describe Other
Please provide the names of staff and/or volunteers involved (if known)
Please describe your concern in detail. (Include dates, locations, people present, activities, etc.)
Please provide any steps/actions you have already taken to resolve it informally.
Please explain what you believe would resolve your grievance fairly.
Please provide any supporting documentation, this may include but not limited to emails, letters, photos and/or records, if applicable.
Volunteer
Date/Timeframe of Incident
Please select the type that best describes your concern:
Conduct of a staff member
Conduct of another volunteer
Organizational policy or practice
Health and safety concern
Unfair treatment
Other
Please Describe Other
Please provide the names of staff and/or volunteers involved (if known)
Please describe your concern in detail. (Include dates, locations, people present, activities, etc.)
Please provide any steps/actions you have already taken to resolve it informally.
Please explain what you believe would resolve your grievance fairly.
Please provide any supporting documentation, this may include but not limited to emails, letters, photos and/or records, if applicable.
Staff
Date/Timeframe of Incident
Please select the type that best describes your concern:
Workplace harassment or bullying
Discrimination or unfair treatment
Conflict with a peer or colleague
Conflict or communication issue between departments or teams
Health or safety concern
Supervisor behavior or decision
Changes to employment conditions
Pay, benefits, or scheduling concern
Other
Have you already addressed your grievance with your immediate supervisor?
Yes
No
Please explain why you have not addressed this with your immediate supervisor.
Please provide the names of staff and/or volunteers involved in your grievance.
Provide detail information regarding your grievance. (Include dates, locations, people present, activities, etc.)
Please provide any steps/actions you have already taken to resolve it informally.
Describe how this grievance has impacted you negatively at work.
Please explain how you believe ECAD could effectively resolve your grievance fairly.
Please provide any supporting documentation, this may include but not limited to emails, letters, photos and/or records, if applicable.
Declaration
I confirm that the information I have provided is true and complete to the best of my knowledge. I understand my grievance will be handled confidentially, and I will not experience retaliation or adverse treatment for filing this form in good faith.
Signature
Date
Contact Information