Internal Complaint Forms APPENDIX B Your Name: Date: MM slash DD slash YYYY Date of Alleged Incident(s): MM slash DD slash YYYY Name of Person(s) you have a complaint against: List any witnesses that were present: Where did the incident(s) occur? Please describe the events or conduct that are the basis of your complaint by providing as much factual detail as possible (i.e. specific statements; what, if any, physical contact was involved; any verbal statements; what did you do to avoid the situation, etc:I hereby authorize the School to disclose the information I have provided as it finds necessary in pursuing its investigation. I hereby certify that the information I have provided in this complaint is true and correct and complete to the best of my knowledge and belief. I further understand providing false information in this regard could result in disciplinary action up to and including termination. Signature of Complainant Reset signature Signature locked. Reset to sign again Date: MM slash DD slash YYYY Print Name To be completed by School:Received by: Date: MM slash DD slash YYYY In processing the complaint, Director (or designee) shall abide by the following process: 1. The Director or designee shall use his or her best efforts to talk with the parties identified in the complaint and to ascertain the facts relating to the complaint. 2. In the event that the Director (or designee) finds that a complaint against an employee is valid, the Director (or designee) may take appropriate disciplinary action against the employee. As appropriate, the Director (or designee) may also simply counsel/reprimand employees as to their conduct without initiating formal disciplinary measures. 3. The Director’s (or designee’s) decision relating to the complaint shall be final unless it is appealed to the Board of Directors. The decision of the Board shall be final. General Requirements 1. Confidentiality: All complainants will be notified that information obtained from the complainants and thereafter gathered will be maintained in a manner as confidential as possible, but in some circumstances absolute confidentiality cannot be assured. 2. Non-Retaliation: All complainants will be advised that they will be protected against retaliation as a result of the filing of any complaints or participation in any complaint process. 3. Resolution: The Board (if a complaint is about the Director) or the Director or designee will investigate complaints appropriately under the circumstances and pursuant to the applicable procedures, and if necessary, take appropriate remedial measures to ensure effective resolution of any complaint. AMENDMENT TO EMPLOYEE HANDBOOK This Employee Handbook contains the employment policies and practices of the School in effect at the time of publication. AMA reserves the right to amend, delete or otherwise modify this Handbook at any time provided that such modifications are in writing and duly approved by the employer. Any written changes to the Handbook will be distributed to all employees. No oral statements can in any way alter the provisions of this Handbook. HARASSMENT/DISCRIMINATION/RETALIATION COMPLAINT FORM It is the policy of the School that all of its employees be free from harassment, discrimination, and retaliation. This form is provided for you to report what you believe to be harassment, discrimination, or retaliation so that the School may investigate and take appropriate disciplinary or other action when the facts show that there has been harassment, discrimination, or retaliation. If you are an employee of the School, you may file this form with the Director or Board President. Please review the School’s policies concerning harassment, discrimination, and retaliation for a definition of such unlawful conduct and a description of the types of conduct that are considered unlawful. AMA will undertake every effort to handle the investigation of your complaint in a confidential manner. In that regard, the School will disclose the contents of your complaint only to those persons having a need to know. For example, to conduct its investigation, the School will need to disclose portions of your factual allegations to potential witnesses, including anyone you have identified as having knowledge of the facts on which you are basing your complaint, as well as the alleged offender. In signing this form below, you authorize the School to disclose to others the information you have provided herein, and information you may provide in the future. Please note that the more detailed information you provide, the more likely it is that the School will be able to address your complaint to your satisfaction. Charges of harassment, discrimination, and retaliation are taken very seriously by the School both because of the harm caused by such unlawful conduct, and because of the potential sanctions that may be taken against the offender. It is therefore very important that you report the facts as accurately and completely as possible and that you cooperate fully with the person or persons designated to investigate your complaint. Your Name: Date: MM slash DD slash YYYY Date of Alleged Incident(s): MM slash DD slash YYYY Name of Person(s) you believe harassed, or discriminated or retaliated against, you or someone else: List any witnesses that were present: Where did the incident(s) occur? Please describe the events or conduct that are the basis of your complaint by providing as much factual detail as possible (i.e. specific statements; what, if any, physical contact was involved; any verbal statements; what did you do to avoid the situation, etc.) :I acknowledge that I have read and that I understand the above statements. I hereby authorize the School to disclose the information I have provided as it finds necessary in pursuing its investigation. I hereby certify that the information I have provided in this complaint is true and correct and complete to the best of my knowledge and belief. Signature of Complainant Reset signature Signature locked. Reset to sign again Date: MM slash DD slash YYYY Print Name Received by: Date: MM slash DD slash YYYY OR Download Form in PDF
