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D H R-L R-001 <br /> (03/01/15) <br /> COUNTY OF HAWAI`I <br /> INTERNAL COMPLAINT FORM <br /> Complainant Name (Last,First,Middle Initial) Employee ❑ <br /> Member of the Public ❑ <br /> County Employment Information,if Applicable (Position Title,Department,Division) <br /> Mailing Address (Street,City,State,Zip) <br /> ❑ Pursuant to the County of Hawai`i's Internal Complaint Procedures, a formal complaint is hereby <br /> submitted. I attempted to resolve this complaint through the informal stage of <br /> the procedure on with <br /> Date <br /> ❑ I did not attempt to resolve this complaint informally, because: <br /> A. Statement of Complaint <br /> 1. Date of action or incident giving rise to this complaint: <br /> 2. Law, Rule, Regulation, Policy or Procedure allegedly violated: (listed below) <br /> 3. Nature of complaint: (provide an explanation of the complaint-attach additional sheets as <br /> necessary) <br /> B. Remedy Sought (Indicate below) <br /> C. Certification <br /> I certify that the above information is true and accurate. <br /> Signature of Complainant Date <br /> Hawaii County is an Eq-ttaCOyyortunity Provider and Emyloyer <br />