Township Employee Concern Report Form

Please make a separate submission to this form for each separate incident that you need to report. A copy of your report will be sent to Township Operations Director, Justin Galias; Township Human Resources Director, Samuel Orozco; and SEIU Local 49 Organizer, Jillian Johnsen.

VANID

Your name:*

First NameLast Name

Your phone number:*

Please enter a valid phone number.Format: (000) 000-0000.

Personal Email

Enter "NONE" if you do not have an email.

Email addresses will be used to send you a copy of your report, along with information on next steps and what to expect.

Date of incident:*

Estimated time of incident:*

Name of the building where incident occurred:*

Name of your manager:*

YesNo

Why not?

Was your concern resolved?

Describe the interaction, problem, or incident that you would like resolved. Please include all relevant details including who, what, where, why, how.*

List the names of any coworkers who witnessed the incident. Provide full names and contact information if you can.*

Upload any pictures, video, audio recordings, or screenshots of text communications related to this incident.