EmailMeForm
Concern Lodgement Form
This form is to be used by employees who have a concern/complaint/grievance that you would like addressed.
Please provide the information below - by confirming your contact details will assist staff at Apex Care to address your concern in a timely manner.
Name
*
First
Last
Role or involvement with Apex Care
*
Phone
*
Email
*
People involved
Type of concern
*
Breach of Apex Policies
Safety Concerns
Harrassment
Discrimination
Abuse
Other
I agree that the information i provide on the following page (Page 2) can be given to the person it concerns in order to investigate.
Please be aware Apex Care may not be able to investigate without first providing evidence of concerns.
I agree
I don't agree but understand Apex Care may not be able to proceed.
The details of my concern are as follows
*
Please include time, place and witnesses
I would like the following action to be undertaken by the business:
*
I attempted to resolve this concern by:
Declaration:
I declare that the information given on this form is true and correct.
Signature:
Clear
Please sign above
Date Time
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/
MM
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