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Employee Statement Form

An employee statement form is used by an employee who is directly involved in an incident, whether as the person raising it or the person it concerns, to give their own written version. It gives them space to explain context, respond to each point and list supporting documents, supporting a fair hearing.

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[Company Logo][Company Name]

EMPLOYEE STATEMENT

Case No.:: [Reference Number]
Date:: [Date]
Classification:: Confidential

1. Employee Details

Employee Name
Employee ID
Designation
Department
Reporting Manager
Role: Person raising the matter / Person the matter concerns / Involved in incident

2. Matter Being Addressed

Incident or matter (as communicated by HR)
Date of incident
Date the matter was communicated to you

3. Your Response

Point Raised	Your Response
[Point 1]	[Response]
[Point 2]	[Response]
[Point 3]	[Response]

4. Additional Information

Your account of events in your own words
Context or circumstances you would like considered
Witnesses who may support your account
Documents attached

5. Declaration

I have written this statement voluntarily and it is true to the best of my knowledge. I understand that this statement will be considered along with other evidence, that no conclusion has yet been reached, and that I will have an opportunity to be heard before any decision. I understand the matter is confidential.

Employee
[Employee Name]
Date: [Date]

Received by
[HR Name]
Date: [Date]

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What this template includes

Employee details and role in the matter
Reference to the incident or allegations
Point-by-point response table
Context and mitigating circumstances
Supporting documents and suggested witnesses
Voluntary statement declaration

When to use it

An employee is asked to explain their side after an incident report
The respondent in a complaint wants to respond in writing before an interview
A complainant wants to add details after the first meeting
An employee involved in a safety incident gives their account

How to customise this template

1List the specific points the employee is asked to respond to
2Give a reasonable deadline to submit the statement
3Allow the statement in the employee's preferred language
4Attach the incident report or allegation summary if appropriate
5Mark it confidential and file it with the case

HR tips

Give the employee enough time and the relevant facts to respond
Do not ask the employee to admit guilt on the form
Accept additional pages without restriction
Use a witness statement form for bystanders instead

For HR & hiring managers

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Frequently asked questions

What is an employee statement?+

A written account by an employee involved in an incident, giving their version of events and any explanation.

Is an employee statement the same as a show-cause reply?+

Not exactly. A show-cause reply answers a formal charge, while an employee statement is often gathered during fact-finding before any charge.

Can the employee refuse to give a statement?+

They can, but the matter may then be decided on the other evidence available. Refusal should be recorded neutrally.

All 50 employee relations & grievances →

[Company Logo][Company Name]
EMPLOYEE GRIEVANCE FORM
Company:
[Company Name]
Grievance Case No.:
[Reference Number]
Date of Submission:
[Date]
Use this form to formally raise a work-related grievance. Please write clearly and attach any supporting documents. Complaints of sexual harassment must be submitted to the Internal Committee under the company's POSH policy and not on this form.
Section A: Employee Details
Employee Name
Employee ID
Designation
Department
Work Location
Reporting Manager
Mobile Number
Official Email
Section B: Nature of Grievance
- Salary, wages, overtime or deductions
- Leave or attendance
- Working conditions, shift or safety
- Transfer, promotion or appraisal
- Interpersonal issue with a colleague or manager
- Application of a company policy
- Other (please specify)
Form · Word
Employee Grievance Form
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[Company Logo][Company Name]
EMPLOYEE COMPLAINT FORM
Company:
[Company Name]
Complaint No.:
[Reference Number]
Date:
[Date]
This form is used to report conduct that you believe breaches company rules or the code of conduct. All complaints are treated confidentially. If your complaint relates to sexual harassment, please approach the Internal Committee directly as per the company's POSH policy.
1. Complainant Details
Employee Name
Employee ID
Designation
Department
Work Location
Contact Number
Preferred mode of contact
2. Person(s) Complained Against
Name
Designation / Role
Department or Organisation (if vendor/customer)
Relationship to you (colleague, supervisor, vendor, other)
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Employee Complaint Form
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[Company Logo][Company Name]
EMPLOYEE COUNSELLING FORM
Ref. No.:
[Reference Number]
Date of Session:
[Date]
Record Type:
Non-disciplinary
Employee Details
Employee Name
Employee ID
Designation
Department
Reporting Manager
Counselled by (name and designation)
Area of Concern
- Work quality or targets
- Attendance or punctuality
- Workplace behaviour
- Adherence to process or policy
- Other
Discussion
Form · Word
Employee Counselling Form
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[Company Logo][Company Name]
EMPLOYEE CONCERN FORM
Company:
[Company Name]
Form No.:
[Reference Number]
Date:
[Date]
Use this form to share an early concern, question or suggestion. It is informal and confidential. For safety emergencies, contact your supervisor immediately. For sexual harassment, please contact the Internal Committee at [IC Email].
Your Details (optional)
Employee Name
Employee ID
Department
Preferred contact (email / phone)
What is your concern about?
- Workload or working hours
- Wellbeing or stress
- Team or manager communication
- Clarity on a company policy
- Change in the organisation (shift, location, structure)
- Tools, systems or resources
- Suggestion for improvement
- Other
Form · Word
Employee Concern Form
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[Company Logo][Company Name]
EMPLOYEE RELATIONS CASE FORM
Case No.:
[Reference Number]
Date Opened:
[Date]
Opened by:
[HR Name]
Classification:
Confidential
A. Case Source
- Employee (written)
- Employee (verbal)
- Manager referral
- Ethics / whistleblower channel
- Exit interview
- Other
B. Case Type
- Grievance
- Conduct complaint
- Bullying / behaviour
- Discrimination
- Retaliation
- Attendance / performance
- Workplace conflict
- Sexual harassment (refer to Internal Committee)
- Other
C. Parties
Form · Word
Employee Relations Case Form
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[Company Logo][Company Name]
WITNESS STATEMENT
Case No.:
[Reference Number]
Date of Statement:
[Date]
Classification:
Confidential
Witness Details
Full Name
Employee ID / Gate Pass No.
Designation
Department
Work Location
Relationship to persons involved (colleague, supervisor, none)
Incident Witnessed
Date of incident
Approximate time
Exact place (floor, room, line, area)
Persons involved
Other persons present
My Account
Form · Word
Witness Statement Form
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[Company Logo][Company Name]
ACKNOWLEDGEMENT OF GRIEVANCE
Ref. No.:
[Reference Number]
Date:
[Date]
To,
[Employee Name]
[Designation], [Department]
Employee ID: [Employee ID]
[Work Location]
Subject: Acknowledgement of your grievance dated [Date]
Dear [Employee Name],
We acknowledge receipt of your grievance submitted on [Date] regarding [brief neutral description of grievance]. It has been registered under case number [Reference Number]. Please quote this number in all future communication on this matter.
Your grievance has been assigned to [Reviewer Name], [Reviewer Designation], who will review the matter in line with the company's Grievance Redressal Policy. The next steps are:
Letter · Word
Employee Grievance Acknowledgement
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[Company Logo][Company Name]
GRIEVANCE INVESTIGATION FORM
Case No.:
[Reference Number]
Date Opened:
[Date]
Classification:
Strictly Confidential
Part 1: Case Details
Complainant [Employee Name], [Employee ID], [Department]
Respondent (if any): Name, Designation, Department
Date grievance received
Grievance category
Part 2: Terms of Reference
Issue 1 to be investigated
Issue 2 to be investigated
Issue 3 to be investigated
Matters outside scope (if any)
Target completion date
Part 3: Investigator Appointment and Independence
Form · Word
Grievance Investigation Form
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