MG TEST - BE4ALL

Rapid Response Protocol – Member Complaint Form

MEMBER INFORMATION

Name(Required)

IA Number(Required)

Local #(Required)

Email Address(Required)

Phone Number(Required)

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

DETAILS OF COMPLAINT

Please click on Add Entry to provide more information about your complaint. You may submit multiple entries if you have more than one incident to report.

Details of Complaint

Incident Date	Describe the Incident(s) (include the location of the incident, who was involved, any injuries, etc.).	Actions

There are no Entries.

By signing this complaint form, I affirm to the best of my knowledge that the information contained herein is true and factual, while also establishing consent and release of the above information to my local union/regional council for the purposes of an investigation. I understand that the completion of this form does not constitute the filing of a complaint with my employer or government agency and does not extend the time for filing a grievance or a complaint with my employer, an outside agency or in a court of law.

Member Signature(Required)

Date(Required)