Supervisor Feedback Reporting
Please fill out the following form to report Supervisor feedback. Please note that any supervisor or managerial behaviour that constitutes sexual harassment or any other form of harassment should be reported to the executive immediately at (416) 845-0597. Thank you very much for your time your input is extremely valuable. Please note that we cannot guarantee anonymity or security due to the nature of this online form. We intend to gather this information to identify trends and suggest improvements for managerial relations. The information submitted in this form may be shared with management. If you wish to make a confidential complaint please call (416) 845-0597.
Your name and partner's name (if applicable):
Date of incident or estimate: *
Time of incident or estimate:
What position does the managerial staff person hold? (Check all that apply) *
I am filing a: *
For a concern or compliment, please provide a description of the event. Do not include names other than yours, and the Supervisor. Addresses or any other confidential information should not be listed. *
Name of managerial staff:
Was this related to a staging call? *
Have you had previous difficult interactions with this supervisor?
Clear selection
Did you feel you were put in harm's way or an unnecessarily risky situation because of this individual?
Clear selection
Nature of complaint (select all that apply) *
What was the context and setting of the interaction?
Stress Leave
Attendance management
Patient care
Lunch/meal break issue
End of shift
Offload delay
At hospital
In front of patient
In front of bystanders
In front of peers
In private
At station
On phone
Clear selection
Going forward, did this interaction negatively affect your working relationship with the supervisor?
Clear selection
Are there any other comments or suggestions, you would like to add?
Did you report the issue to the individual's superior?
Clear selection
Name of superior you reported the incident to:
If "yes" to previous question, did the superior take action?
Clear selection
What constructive criticism could you offer to improve this individual's behaviour?
Clear selection
Was this form helpful?
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