Pokeka Complaint Form

Pokeka Concerns/Complaint Form

This form is for kaimahi (staff) and/or whaiora (clients) / whānau (families) to lay a complaint or report the behaviour or misconduct of kaimahi. This form is designed to provide a structured and confidential way for kaimahi, whaiora, and whānau to raise concerns, report misconduct, or lodge complaints regarding the behavior or actions of kaimahi. It aims to ensure that all concerns are addressed fairly, respectfully, and in alignment with our organisation's values.
Record the details of the complaint/report below and submit the form once all fields are completed. This form will then be sent to HR with a copy being provided to your pou lead (if appropriate).
Details
Name*

First NameLast Name
Position*
Kaimahi or Whaiora
Email*
example@example.com
Who is the concern/complaint about? *

First NameLast Name
If the concern/complaint is for more than one person, please submit a form for each one.
Analysis
Please state the date & time of the incident *

DayMonthYear
Date
Hour MinutesAM/PM Option
Please state the nature of the concern/complaint*
When did the situation happen? *
Where did the situation occur? *
Witnesses (if any)?*

YesNo
Witness Details
Name*

First NameLast Name
Waea pūkoro*
Please enter a valid phone number.
Please provide any supporting evidence (if applicable)*
File Upload

Cancelof
Do you believe it is bullying?*

YesNo
Please provide details as to why you believe it is unreasonable/unnacceptable *
Has it endangered your health and safety?*

YesNo
If yes, please provide details as to how it has endangered your health and saftey*
Please provide detail as to how this situation made you feel*
Has this incident affected your mahi?*

YesNo
If yes, please provide details as to how it has affected your mahi *
Have you taken any actions to mitigate the situation?*

YesNo
If yes, please provide details as to what actions you have taken*
What outcome do you expect to be achieved as a result of filing this concern/complaint? *
Should a copy of this report be provided to your Pou Lead?*

YesNo
Please select your Pou Lead *
Pou Lead Imēra*
Declaration*

I confirm that the information provided in this complaint/concern is accurate to the best of my knowledge.Confidentiality Disclosure - This complaint/concern will be treated with strict confidentiality and shared only with those directly involved in the resolution process, as required. Any sharing of this information will comply with relevant policies and laws. If you have specific concerns regarding confidentiality, please indicate them below:
Specific concerns
Date*

MonthDayYear
Date
Signature*

Clear
Enquiries Email
example@example.com
Should be Empty:

Pokeka Concerns/Complaint Form

Details

Analysis