EMPLOYEE COMPLAINT/INCIDENT FORM

Georgia Southern University takes employee complaints, unethical behavior, inconsistent management practices, or unfair conduct as a serious matter. Any employee filing a complaint must fill out this form completely and submit it to Dr. Ale Kennedy. Please use additional sheets of paper if necessary. Please note: Any Sexual Harassment or Discrimination complaints should be referred to the Director of EEO & Title IX.

Complainant’s Name: __________________________________________________________ Position: ________________________________ Department: _____________________________ 1. Please describe in as much detail as possible the nature of your complaint (attach a separate sheet if needed). Please provide or identify all known persons, documents, or witnesses to your concerns:

2. For Human Resources’ coordination of response, please advise if you have raised this complaint/concern with the University’s Ethics and Compliance Hotline, Equal Opportunity & Title IX Office, or any other office within the University? Yes

No

3. Please describe how the actions you complain about have affected your ability to perform your job.

EMPLOYEE COMPLAINT/INCIDENT FORM 4. Please explain any positive solutions you believe can help resolve your complaint.

5. Please provide any additional comments you wish the institution to consider when investigating your complaint.

By signing I acknowledge that the information stated in this document is accurate and factual. I also understand that I have an obligation to provide information as needed and to cooperate fully and completely with any investigation of this complaint. Signature: _______________________________ Date: _______________________________

Filing Instructions: This form should be submitted to the Associate Vice President for Human Resources or the Director of Employee Relations, P.O. Box 8104.