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* 1. Name (Optional)

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* 2. Date / Time of Event

Date
Time

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* 3. Can you give us a complete account of the event that occurred or grievances you have?

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* 4. What is a solution you think would help for the future?

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* 5. What is the outcome you hope to see?

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* 6. If you would like to set up a meeting with HR, please list your name as well as dates and times you would be available for a confidential and protected meeting? (Optional)

T