Complaint Form Pdf Download - Free Download
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Complaint Form Pdf Download
Complaint Form Pdf Download
Human Resources
PPSM 70 Complaint (Required by Berkeley Procedure 70)
A. Complainant
Last Name:
First Name:
Middle Initial:
Payroll Title:
Hire Date (M/D/Y):
Home Address:
Home/Cell Phone No.:
Work Phone No.:
Email Address:
B. Supervisor
Last Name:
First Name:
Email Address:
Work Phone No.:
C. Representative (if any)
Last Name:
First Name:
Phone No.:
Email Address:
D. Informal Resolution
Please attach a statement that identifies and details your informal resolution attempt(s), including the dates of such attempts, and
the name(s) of the person(s) contacted.
E. Statement
Please attach a statement detailing:
(1) which University policies were violated, including the specific sections of such policies;
(2) the specific management act(s) that gave rise to your complaint;
(3) when the act(s) occurred (or when you became aware of such act(s));
(4) how the act(s) violated the specified University policies; and
(5) how you were adversely affected.
F. Remedy
Please describe your requested remedy.
For Human Resources Use Only
Complaint No.: Date Received:
Appealable to Step II
Eligible for Factfinding
Appealable to Step III
PPSM 70 Complaint Form Revised 6/2014
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