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Retaliation Complaint Form

A retaliation complaint form is for an employee who believes they were punished or treated unfavourably because they raised a grievance, complaint, whistleblower report or took part as a witness. It links the earlier protected report to the adverse action through a timeline, so HR can review it urgently and independently.

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[Company Logo][Company Name]

RETALIATION COMPLAINT FORM

Company:: [Company Name]
Complaint No.:: [Reference Number]
Date:: [Date]
Classification:: Strictly Confidential – Priority

1. Your Details

Employee Name
Employee ID
Designation
Department
Safe contact number / email

2. Your Original Report or Participation

I raised a grievance
I made a complaint
I made a whistleblower / ethics report
I filed a complaint with the Internal Committee (POSH)
I was a witness in an inquiry
Other

Date of original report
Case / reference number (if known)
To whom it was made

3. Adverse Treatment

Lower rating or negative feedback
Transfer, shift or role change
Removal of duties or exclusion
Threats or hostile remarks
Leave, increment or training denied
Other

4. Timeline

Date	Event	Person Involved	Evidence
[DD/MM/YYYY]	Original report made	[Name]	[Ref.]
[DD/MM/YYYY]	[Adverse action]	[Name]	[Evidence]
[DD/MM/YYYY]	[Adverse action]	[Name]	[Evidence]

5. Why You Believe This Is Retaliation

Explanation
Witnesses
Urgent protection requested

I declare that this complaint is made in good faith and is true to my knowledge. I understand that it will be reviewed confidentially and as a priority by a person independent of those involved, and that any further retaliation will be treated as serious misconduct.

Complainant
[Employee Name]
Date: [Date]

Received by
[HR Head]
Date: [Date]

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What this template includes

Details of the original protected report or participation
Adverse action complained of
Timeline connecting the report and the action
Person believed responsible
Evidence such as revised rosters or messages
Urgent protection needed
Review by someone senior and independent

When to use it

An employee's rating, shift or role changed soon after they raised a complaint
A witness in an inquiry is being excluded or threatened by the respondent's team
A whistleblower faces sudden transfer or loss of responsibilities
A POSH complainant reports victimisation after filing with the Internal Committee

How to customise this template

1Route this form to the HR head or ethics committee, not the line manager
2Reference the case number of the original report
3For POSH victimisation, copy the Internal Committee
4Add your whistleblower or vigil mechanism contact
5Commit to a priority review in your policy

HR tips

Treat retaliation complaints as high priority
Pause the adverse action, where possible, while the review happens
Ask the decision-maker to document legitimate reasons for the action
Retaliation, if proved, should be treated as serious misconduct

This template is a starting point. Review it against applicable laws, the POSH Act 2013 where relevant, your whistleblower and grievance policies, and with a legal adviser.

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Frequently asked questions

What is workplace retaliation?+

Any unfavourable action taken against an employee because they raised a concern, complaint or grievance, or took part in an investigation.

What are examples of retaliation?+

Sudden poor ratings, transfer, removal of duties, exclusion, threats, or denial of leave or increments after a complaint.

Who handles a retaliation complaint?+

A senior HR leader or ethics committee independent of the people involved, with urgency.

All 50 employee relations & grievances →

[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]
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
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[Company Logo][Company Name]
BULLYING COMPLAINT FORM
Company:
[Company Name]
Complaint No.:
[Reference Number]
Date:
[Date]
Classification:
Confidential
Section 1: Your Details
Employee Name
Employee ID
Designation
Department
Reporting Manager
Safe contact number / email
Section 2: Person(s) Alleged to be Bullying
Name(s) and designation(s)
Relationship: Manager / Senior / Peer / Junior / Group
Section 3: Type of Behaviour
Form · Word
Bullying Complaint Form
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[Company Logo][Company Name]
HARASSMENT COMPLAINT FORM
Company:
[Company Name]
Complaint No.:
[Reference Number]
Date of Submission:
[Date]
Classification:
Strictly Confidential
Section A: Where This Complaint Goes
- Sexual harassment: To the Presiding Officer, Internal Committee, [IC Presiding Officer Name], [IC Email]
- Other harassment (caste, religion, region, disability, appearance or other): To Human Resources, [HR Name], [HR Email]
Section B: Complainant Details
Name
Employee ID
Designation
Department
Work Location
Safe contact number / email
Section C: Respondent Details
Form · Word
Harassment Complaint Form
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[Company Logo][Company Name]
DISCRIMINATION COMPLAINT FORM
Company:
[Company Name]
Complaint No.:
[Reference Number]
Date:
[Date]
Classification:
Confidential
Part 1: Complainant
Employee Name
Employee ID
Designation
Department
Date of Joining
Contact Number / Email
Part 2: Ground of Discrimination
- Gender
- Pregnancy or maternity
- Caste or community
- Religion
- Disability or health condition
- Age
- Region, language or place of origin
- Marital status
- Other
Part 3: Treatment Complained Of
Form · Word
Discrimination Complaint Form
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[Company Logo][Company Name]
ETHICS COMPLAINT FORM
To:
Ethics Committee / Compliance Officer, [Company Name]
Reference No.:
[Reference Number]
Date:
[Date]
Use this form to report a suspected breach of the Code of Conduct. You may remain anonymous. Submit to [Ethics Email] or the sealed ethics box at [Location]. Sexual harassment complaints should be made to the Internal Committee.
Reporter (optional)
Name
Employee ID / Vendor Code
Department
Contact (email / phone)
I wish to remain anonymous (Yes / No)
Type of Concern
- Undisclosed conflict of interest
- Gifts, hospitality or cash against policy
- Bribery or kickbacks
- Favouritism in hiring or vendor selection
- Misuse of company assets
- Data privacy or confidentiality breach
- Falsification of records or expenses
- Other code of conduct breach
Form · Word
Ethics Complaint Form
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[Company Logo][Company Name]
PROTECTED DISCLOSURE / WHISTLEBLOWER COMPLAINT
To:
Vigilance Officer, [Company Name] / Chairperson, Audit Committee
Reference No.:
[Reference Number]
Date:
[Date]
This disclosure is made under the company's Whistleblower / Vigil Mechanism Policy. Mark the envelope 'Protected Disclosure – Confidential' or email [Vigilance Email]. Your identity will be protected.
1. Whistleblower Details (kept separately and confidential)
Name
Employee ID
Designation / Department
Safe contact
I wish to remain anonymous (Yes / No)
2. Nature of Wrongdoing
- Financial fraud or misappropriation
- Manipulation of accounts or records
- Violation of law or regulation
- Falsification of safety, quality or test data
- Abuse of authority
- Leak of confidential or price-sensitive information
- Other serious wrongdoing
Form · Word
Whistleblower Complaint 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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