SOP 104.43-att-1: Complaint Form

SOP 104.43
Attachment 1

5/31/18

Georgia Department of Corrections

Complaint Form

Employee Name Employee ID#

Complete Home Address
Street Name, Apartment#, or P. O. Box#

City State Zip

Job Title Home Phone

Facility/Office Work Phone

Name and Job Title of person against whom complaint is being filed:

Date the problem occurred or when you first became aware of the problem:

Employee complaint (attach additional sheets as needed):

If Complaint involves interpretation or application of a State Personnel Board Rule [SPBR] or
a Standard Operating Procedure [SOP], then specify the rule(s) or procedure(s):

How has your employment been unfavorably affected by this problem?

Relief Requested:

Employee Signature Date

Mail original copy of this Complaint Form, with any attachments, to:

Agency Complaint Resolution Coordinator

Central HR/Gibson Hall/2 [nd ] Floor

P. O. Box 1529
Forsyth, Georgia 31029

(478) 992-5204

Retention Schedule: Upon completion, this form shall be retained by the Agency Complaint Resolution Coordinator for a minimum of four (4) years
for Complaints alleging discrimination or harassment based on race and a minimum of two (2) years for all other Complaints.