Nkadimeng Danny Legal & Compliance Support
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EMPLOYEE GRIEVANCE FORM

SECTION A – EMPLOYEE DETAILS
Full name: ____________________________________
Employee number: _____________________________
Position: _____________________________________
Department: __________________________________
Date of submission: ___________________________

SECTION B – NATURE OF GRIEVANCE
(Please tick where applicable)
[ ] Working conditions     [ ] Treatment by colleague/manager
[ ] Discrimination / harassment    [ ] Remuneration / benefits
[ ] Disciplinary process    [ ] Health and safety
[ ] Other (specify): _______________________________

SECTION C – DESCRIPTION
Please describe what happened, when, where, and who was involved. Attach copies of any supporting documents.
________________________________________________
________________________________________________
________________________________________________
________________________________________________

SECTION D – STEPS ALREADY TAKEN
Did you raise this informally? With whom? What was the outcome?
________________________________________________
________________________________________________

SECTION E – DESIRED OUTCOME
What resolution are you seeking?
________________________________________________
________________________________________________

SECTION F – WITNESSES (optional)
1. Name: ___________________ Contact: ___________
2. Name: ___________________ Contact: ___________

SECTION G – DECLARATION
I confirm that the information provided above is true and correct to the best of my knowledge.

Employee signature: __________________  Date: __________

FOR OFFICIAL USE
Received by: _________________  Date: __________
Reference no.: _______________
Allocated to: ________________
Acknowledged in writing to employee on: __________

This template is a starting point and not legal advice. Adapt to your workplace policy.