Grievance and Complaint Form

Incident Type:*Verbal AltercationPhysical AltercationGeneral Complaint

Are you a member?*YesNo

Your Full Name:*

Preferred Communication Method:*PhoneEmail

Phone:*

Email:*

Street Address:*

Street Address (line 2):

City:*

State:*

Postal / ZIP Code:*

Please tell us who you have a complaint against.:*

Select The Status Of The Violator:*MemberStaffContractor

Please describe the conduct or incident(s) that is the basis of this complaint.*

Please provide specific date(s) the incident occurred.*

Additionally, please advise if this conduct has been ongoing or is this a first time?*OngoingFirst time

Please list the name and contact information of any witnesses or individuals that may have information related to your complaint.*

Have you previously complained or provided information (verbal or written) about a violation of the Church’s sexual harassment policy to the Church?*YesNo

When and to whom did you complain or provide information?*

I am requesting that the Church investigate this complaint in a timely and confidential manner and advise me of the results of the investigation.*I agree

Signature:*

Date:*