Internal Complaint Report

Internal Complaint Form

This Internal Complaint Form is received only by the Agency Chief. No other members of management will receive this complaint form in its entirety.

This Form and its Contents are Confidential and are ONLY seen by the Chief of Operations.
Please understand that not reporting a violation, real or percieved, of a STEMS policy, State or Federal Law, unsafe action, act detrimental to STEMS reputation, or an act detrimental or dangerous to the workplace only prevents or delays STEMS management from addressing the issue. SOP 100.03.10 Policy Violation Reporting
Name of Provider Making the Complaint
First Last
Not required, but strongly recommended in order to evaluate your complaint. While anonymous complaints will be evaulated, complaints may require follow up in order to determine the extent and severity of the issue. If Management is unable to follow up, we may not be able to properly address the complaint.
Date of Incident*
MM slash DD slash YYYY
Time of incident*

: Hours

Minutes

AM/PM

Approximate time of the incident
Location the Incident Occured*
Street Address Address Line 2 City State ZIP Code
Person Involved (1)
First Last
Person Involved (2)
First Last
Person Involved (3)
First Last
Description of the Complaint*
Uploaded Files related to Complaint
Drop files here or

Max. file size: 32 MB, Max. files: 4.
Can We Contact you about the Complaint?*
Contact Number
False Report: You are prohibited from knowingly or intentionally making a report of non-compliance that is false. Person/s who knowingly and intentionally make a false report of non-compliance may also be subjected to the full range of available sanctions, up to and including termination of employment. SOP 100.03.09 Anti-Retaliation Policy
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