Incident / Complaint Report Form
Date Received on:_____
BY:_____
<div style="text-align: center;"><img src="imgs/img_in_image_box_0_0_636_78.jpg" alt="Image" width="99%" /></div>
Complainant's Name: ___
Mailing Address: ___
Phone: ___
Complainant's Status:
□ Employee □ Job Applicant
Department Customer
Date, time, and place of the incident(s): ___
Documentation:
Please attach copies of any documents or material you believe are relevant.
Witnesses:
Did anyone witness the incident(s)? If so, please list names and phone numbers of any witnesses to the incident(s). Use additional pages, if necessary.
Name: ___
_Phone: _____
Name: ___
_Phone: _____