Ethics & Grievance Reporting Form

Purpose: This form allows employees, contractors, and external partners to confidentially report concerns related to unethical conduct, discrimination, harassment, safety, compliance violations, or other grievances.

You may submit this form without identifying yourself. However, providing contact information allows Leaders Staffing to follow up if additional details are needed to complete the investigation.

Full Name *

Employee ID (if applicable)

Job Title / Department *

Phone *

Email *

Preferred Method of Contact *

Phone

Other

Anonymous

Relationship to Company *

Current Employee

Former Employee

Contractor

Applicant

Vendor

Other

If Other, please specify:

Type of Report *

Ethical Concern

Harassment

Discrimination

Safety Violation

Retaliation

Wage/Hour Issue

Fraud/Misconduct

Other

If Other, please specify here:

Date(s) of Incident(s) *

Time(s) of Incident(s) *

Location(s) of Incident(s) *

Name(s) of Person(s) Involved *

Witness(es) (if any) *

Description of Incident *

Do you have supporting evidence? *

Yes
No
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If yes, please describe or attach files (emails, photos, screenshots, etc.)

Have you previously reported this concern? *

Yes
No
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If yes, to whom and when? *

What was the outcome?

What outcome are you seeking? *

Confidentiality Notice: Leaders Staffing will treat all reports seriously and confidentially to the extent possible. Retaliation against any person who submits a good-faith report is strictly prohibited.

I affirm that the information provided is true to the best of my knowledge. *

Clear

Date Signed *