5 STAR Sharing Form:

Our company takes all feedback, good and bad — including complaints of discrimination, harassment, unethical conduct or policy/safety violations, as serious matters. So that we may properly investigate your concern, you are requested to fill out this form completely and return it as soon as possible. Any information exchanged can create a stronger, more harmonious workplace. Positive and negative feedback is important because it helps us to work more effectively toward our goals. Kudos shouldn’t only come from supervisors and managers. It should be going up, down, sideways, really all directions you can think of within an organization.

Some tips:

1. Give timely, ‘live’ feedback.

2. Use tact, but don’t sugarcoat anything.

3. Be specific and provide context.

4. Express appreciation.

Name (Optional - Leave Blank to Submit Anonymously)

First

Last

Would you like to be contacted about your feedback? *

• Yes
• No

Email Address

Address (Number, Street, City, State, Zip)

Phone Number:

Date of Birth:

Type: *

• Employee
• Patron
• Visitor

Reason for Sharing: *

Nature of Feedback: *

• Complaint
• Kudos (Good Job)
• Accident/Injury
• Verbal Confrontation
• Other (describe below)

Other Description:

Date of Incident:

Location of Incident

Specific Location of Accident/Incident (address/vicinity/actual location):

Incident occurred at:

• Via Email
• On the Phone
• Inside Venue
• Outside Venue
• Other Location (specify below)

Other Incident Location:

Please explain what happened: *

Please include any additional information regarding your feedback:

Are there any other employees you know of with a similar feedback?

Name of Witness (if applicable)

Witness Phone #:

Please describe any solutions you believe can help resolve your feedback.

Please provide any additional matter or comments you wish the company to consider when reviewing your feedback:

Submit