Free form template · Word

Mediation Request Form

A mediation request form is used by an employee, manager or HR to ask for a neutral mediator to help resolve a dispute between colleagues. It captures the parties, a short description of the issue, each party's willingness to participate voluntarily, availability and any preference for an internal or external mediator.

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[Company Logo][Company Name]

MEDIATION REQUEST FORM

Company:: [Company Name]
Request No.:: [Reference Number]
Date:: [Date]

1. Person Requesting Mediation

Name	[Employee Name]
Employee ID	[Employee ID]
Designation / Department
Role: Party to dispute / Manager / HR

2. Other Party / Parties

Name
Designation
Department
Has the other party been informed? (Yes/No)

3. Summary of the Dispute

Brief description (no more than a few lines)
How long has it been going on?
Earlier steps taken
What would a good outcome look like for you?

4. Preferences

Mediator: Internal HR / Trained colleague / External mediator / No preference
Preferred language
Available days and times
Any adjustment needed

5. Suitability Check (HR)

Dispute is interpersonal and not an allegation of sexual harassment (POSH matters go to the Internal Committee)
No pending disciplinary inquiry on the same facts
Both parties willing to participate voluntarily
Mediator has no conflict of interest

I request mediation voluntarily. I understand that mediation is confidential, that I may withdraw at any stage, that it does not affect my right to use the grievance procedure, and that no one will be treated unfavourably for requesting or declining mediation.

Requester
[Employee Name]
Date: [Date]

HR
[HR Name]
Date: [Date]

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What this template includes

Requester details and their role in the dispute
Other party details
Short summary without detailed allegations
Voluntary participation confirmation, since mediation only works if both agree
Mediator preference: internal HR, trained colleague or external
Availability and language preference
Statement that mediation is not suitable for harassment or serious misconduct

When to use it

A conflict has not been resolved through direct conversation or manager support
A grievance outcome recommends mediation between the parties
Two senior employees prefer a confidential, non-disciplinary route
A team is returning to work together after a dispute and needs a reset

How to customise this template

1Name your trained internal mediators or external provider
2Add any cost approval needed for an external mediator
3Translate the form for non-English speakers
4Set a turnaround for HR to contact the other party
5Link it to your mediation agreement template

HR tips

Approach the other party privately and let them decline without pressure
Choose a mediator outside both reporting lines
Do not use mediation where there is a power imbalance from harassment; POSH complaints go to the Internal Committee
Keep mediation notes separate from personnel files

For HR & hiring managers

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Frequently asked questions

What is workplace mediation?+

A voluntary, confidential process where a neutral mediator helps two or more employees discuss a dispute and reach their own agreement.

Is mediation compulsory?+

No. Mediation is voluntary and either party can decline or withdraw. Other routes such as the grievance process remain open.

Can mediation be used for sexual harassment complaints?+

Under the POSH Act 2013, the Internal Committee may attempt conciliation only at the request of the aggrieved woman and without monetary settlement. General workplace mediation should not replace the IC process.

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Form · Word
Open Door Request Form
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[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)
Form · Word
Employee Complaint Form
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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
Download .docx
[Company Logo][Company Name]
WORKPLACE COMPLAINT FORM
Site / Unit:
[Work Location]
Form No.:
[Reference Number]
Date:
[Date]
Anyone working at this site may use this form. You may give your name or leave it blank. For complaints of sexual harassment please contact the Internal Committee: [IC Presiding Officer Name], [Phone].
About You (optional)
Name
Employee ID / Gate Pass No.
Category: Employee / Contract Worker / Trainee / Apprentice
Contractor Company (if applicable)
Department / Line
Shift
Contact Number
Type of Complaint
- Safety hazard or unsafe practice
- Washroom, drinking water or hygiene
- Canteen or food quality
- Transport or shuttle
- Wages, overtime or deductions
- Behaviour of a person
- Equipment, PPE or tools
- Other
Form · Word
Workplace Complaint Form
Download .docx
[Company Logo][Company Name]
WORKPLACE CONFLICT FORM
Company:
[Company Name]
Form No.:
[Reference Number]
Date:
[Date]
1. Submitted By
Name [Employee Name]
Employee ID [Employee ID]
Designation / Department
Submitting as: Party to the conflict / Manager / Other
2. Parties Involved
Name Designation Department Working Relationship
[Employee Name] [Designation] [Department] [Peer / Reports to / Cross-team]
[Employee Name] [Designation] [Department] [Relationship]
3. Nature of Conflict
Form · Word
Workplace Conflict Form
Download .docx
[Company Logo][Company Name]
CONFLICT RESOLUTION FORM
Ref. No.:
[Reference Number]
Meeting Date:
[Date]
Facilitator:
[Facilitator Name], [Designation]
Parties
Party A [Employee Name], [Designation], [Department]
Party B [Employee Name], [Designation], [Department]
Issues Discussed
1. [Issue 1, e.g., allocation of client follow-ups]
2. [Issue 2, e.g., tone in team chat]
3. [Issue 3]
Agreed Commitments
Form · Word
Conflict Resolution Form
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[Company Logo][Company Name]
WORKPLACE MEDIATION AGREEMENT
Ref. No.:
[Reference Number]
Date:
[Date]
Place:
[Work Location]
This Mediation Agreement is made on [Date] at [Company Name], [Company Address], between:
Party A: [Employee Name], [Designation], [Department], Employee ID [Employee ID]
Party B: [Employee Name], [Designation], [Department], Employee ID [Employee ID]
and facilitated by the Mediator: [Mediator Name], [Designation / Organisation].
Terms
1. Voluntary participation: Both parties take part voluntarily and may withdraw at any time by informing the Mediator.
2. Role of Mediator: The Mediator is neutral, will not take sides, and will not decide who is right. The Mediator helps the parties reach their own agreement.
3. Confidentiality: Discussions in mediation are confidential and will not be used in any disciplinary or grievance proceeding, except where there is a risk to health or safety, or disclosure is required by law.
4. Notes: Any notes made by the Mediator will be destroyed after this agreement is signed, except this agreement itself.
5. Respect: Both parties agree to listen without interruption and to speak respectfully.
6. No retaliation: Neither party will be treated unfavourably for taking part in mediation, and neither will act against the other because of it.
7. Agreed outcomes: The parties agree to the following:
  (a) [Agreed action 1]
  (b) [Agreed action 2]
  (c) [Agreed action 3]
8. Communication to others: [The parties agree that their manager will be told only that mediation was completed / other agreed wording].
9. Review: A review meeting will be held on [Date] with the Mediator or HR to check how the agreement is working.
10. Breach: If either party believes the agreement is not being followed, they may raise it with HR, who may arrange a further meeting or use other company procedures.
11. Other rights: This agreement does not take away any right either party has under company policy or law.
Signed copies are kept by each party and one copy by HR in a confidential file.
Party A
[Employee Name]
Date: [Date]
Party B
[Employee Name]
Date: [Date]
Mediator
[Mediator Name]
Date: [Date]
Agreement · Word
Mediation Agreement
Download .docx

I would like to meet	[Leader Name / Designation] or HR Head
Preferred date(s) and time
Mode: In person / Phone / Video call
Approximate time needed

Mediation Request Form

Preview of the form

1. Person Requesting Mediation

2. Other Party / Parties

3. Summary of the Dispute

4. Preferences

5. Suitability Check (HR)

What this template includes

When to use it

How to customise this template

HR tips

Frequently asked questions

Employee Details

Meeting Request

Topic

Open Door Request Form

Section A: Employee Details

Section B: Nature of Grievance

Employee Grievance Form

1. Complainant Details

2. Person(s) Complained Against

Employee Complaint Form

Part 1: Case Details

Part 2: Terms of Reference

Part 3: Investigator Appointment and Independence

Grievance Investigation Form

About You (optional)

Type of Complaint

Workplace Complaint Form

1. Submitted By

2. Parties Involved

3. Nature of Conflict

Workplace Conflict Form

Parties

Issues Discussed

Agreed Commitments

Conflict Resolution Form

Terms

Mediation Agreement

Employee Name
Employee ID
Designation
Department
Reporting Manager
Contact Number / Email

Name
Designation / Role
Department or Organisation (if vendor/customer)
Relationship to you (colleague, supervisor, vendor, other)

Complainant	[Employee Name], [Employee ID], [Department]
Respondent (if any): Name, Designation, Department
Date grievance received
Grievance category

Issue 1 to be investigated
Issue 2 to be investigated
Issue 3 to be investigated
Matters outside scope (if any)
Target completion date

Name
Employee ID / Gate Pass No.
Category: Employee / Contract Worker / Trainee / Apprentice
Contractor Company (if applicable)
Department / Line
Shift
Contact Number

Name	Designation	Department	Working Relationship
[Employee Name]	[Designation]	[Department]	[Peer / Reports to / Cross-team]
[Employee Name]	[Designation]	[Department]	[Relationship]

Party A	[Employee Name], [Designation], [Department]
Party B	[Employee Name], [Designation], [Department]

Mediation Request Form

Preview of the form

1. Person Requesting Mediation

2. Other Party / Parties

3. Summary of the Dispute

4. Preferences

5. Suitability Check (HR)

What this template includes

When to use it

How to customise this template

HR tips

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Frequently asked questions

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