Employee Grievance

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Employee Grievance

Name *

Enter your FULL name (first and last). If you wish to submit anonymously, please simply write "prefer not to share." NOTE: if you submit anonymously, it limits our abilities to follow up on grievances. We encourage you to include your name for follow-up purposes. The information provided in employee grievances are kept confidential.

Clinic Location *

Please indicate the nature of the grievance: *

Violation of client rights, suspected client abuse/neglect, or endangerment concerns

Interpersonal Issue with a peer (someone you work with who is not your supervisor)

Interpersonal Issue with a supervisor

Working Environment Concerns

Grievance in relation to BCPS Policy, Procedures or Leadership

Discrimination, harassment or bullying

Other:

Required

Does this grievance relate to unsafe or unlawful behavior or an issue that could result in the bodily harm of a client or staff member? *

If YES: ensure that everyone is safe before continuing; notify Jason Cone immediately 252-751-0518 ext 8.

Yes

Do you want to keep this grievance confidential? *

Yes

Please contact me prior to sharing details of this grievance outside of HR

Other:

Required

Clear form

Never submit passwords through Google Forms.

This form was created inside of BCPS. Report Abuse

Forms