Employer Retaliation Incident Log PDF

Track retaliation in one place so you can share a clean PDF with HR, a government agency, or an attorney.

Log suspected retaliation

Keep dates, actions, and impact in one place after you reported harassment, discrimination, safety issues, or wage concerns.

Employee name

Job title

Employer or company

Department

Work location

Report type or summary

Report date

Agency or HR contact

Case or reference number

Log each suspected retaliatory action after your report.

Incident 1

Date

Action type

What happened

Who was involved

Impact

Witnesses

Your response

Overall notes

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