Name: 

[Your Name]

Position/Title: 

[Operations Analyst]

Department:

[Operations]

Supervisor:

[Kenneth Poh]

Date of Grievance:

[Month, Day, Year]

Date of Incident(s):

[Month, Day, Year]

Grievance Details

Please describe the nature of your grievance. Be as specific as possible (include dates, locations, and names of individuals involved):

Has this issue been reported previously?

•  Yes

•  No

If yes, to whom and when? Please provide details:

Affected Areas

Please indicate how this issue has affected your work or well-being (check all that apply):

• Job Performance

•  Work Environment

•  Relationships with Colleagues/Supervisors

•  Mental/Emotional Health

•  Other (Please specify): _______________________________________________

Desired Outcome

What resolution are you seeking? Please specify your desired outcome:

Documentation and Evidence

If applicable, please attach any relevant documents, emails, or other evidence that supports your grievance. Label them clearly and attach them to this form.

Employee Acknowledgment

By signing below, I declare that the information provided here is true and accurate to the best of my knowledge and belief. I understand that any false statements may result in disciplinary action up to and including termination.

Employee Signature: _____________

Date: [Month, Day, Year]

For Official Use Only

Received By: [Harriet Peterson]

Date Received: [Month, Day, Year]

Initial Review Date: [Month, Day, Year]

Follow-Up Actions: 

Resolution: 

Final Resolution Date: [Month, Day, Year]

HR/Management Signature: ______________

Date: [Month, Day, Year]

Note: This form is confidential and will be handled in accordance with applicable U.S. laws and company policies. Your grievance will be investigated promptly, and you will be updated on the progress and outcome. Retaliation against employees for filing a grievance is strictly prohibited.