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Hurt Feelings Complaint Form Template

Create a Safe Space to Address Hurt Feelings

It can be difficult to voice your emotions when you feel hurt or overlooked. This hurt feelings complaint form template is designed to help individuals articulate their grievances in a constructive way, ensuring their concerns are heard and respected. By using this template, you can foster open communication, create a supportive environment, and lead to positive resolutions, whether in a workplace or personal setting. Start using this template to make the process of expressing feelings a little easier and more productive.

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Your full name
Email address
Your relationship to this organization
Employee
Student
Customer/Client
Contractor
Volunteer
Visitor
Prefer not to say
Other
Please Specify:
Date of incident
Location of incident
People involved (names and roles, if known)
Type of behavior
Comment or remark
Joke or teasing
Shouting or raised voice
Exclusion or ignoring
Email or text message
Social media post
Physical gesture
Other
Please Specify:
Describe what happened
Witness names or contact information (if any)
Did this relate to any of the following?
Please Specify:
How has this affected you?
Felt upset or hurt
Felt anxious or stressed
Difficulty concentrating
Avoided the person or situation
Physical symptoms (e.g., headache, stomachache)
Sleep disruption
Prefer not to say
Other
Please Specify:
How are you feeling about the situation right now?
Very unhappy
Unhappy
Neutral
Happy
Very happy
Do you feel safe continuing your usual activities?
Yes
No
What outcome would you like to see?
What support would be most helpful?
Talk with a manager/supervisor
Facilitated conversation or mediation
Information about policies and options
Counseling or employee assistance referral
Written record only (no action requested)
No contact with the other party
No action requested
Other
Please Specify:
Have you already spoken to the other person about this?
Yes
No
Have you reported this to anyone else?
No
Manager/Supervisor
HR/Student services
Security
Union/Representative
Parent/Guardian
Other
Please Specify:
Is this urgent and requires immediate attention?
Yes
No
Preferred contact method for follow-up
Email
Phone
Either email or phone
Do not contact me
Type your full name as signature
Date
I confirm the information provided is accurate to the best of my knowledge.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
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Paper art illustration featuring a complaint form with hurt feelings heading for an article on FormCreatorAI

When to use this form

Use this form when a comment, joke, message, post, or action left you feeling disrespected, bullied, excluded, or targeted. It suits workplaces, clubs, teams, classrooms, and online communities. You can document the event, your impact, and what you want done, so managers or admins can respond fast and fairly. If the issue overlaps with policy or HR matters, you can also route it with a Grievance form. If you fear backlash, you may submit details without your name using an Anonymous complaint form. The result is a clear record that helps leaders investigate, coach, or mediate, and gives you a path to resolution.

Must Ask Hurt Feelings Complaint Questions

  1. What happened, where, and when?

    Specifics make it easier to verify facts and spot patterns. Clear time and place details help your team prioritize and find any records or witnesses.

  2. Who was involved or present, and how did they participate?

    Naming people and roles clarifies responsibility and reduces hearsay. Witnesses allow a fair, balanced follow-up.

  3. How did this affect you and your ability to work, study, or participate?

    Describing impact shows why the issue matters and guides urgency. It also helps decision-makers propose support or accommodations.

  4. What have you already tried to address the issue, and what response did you receive?

    Prior actions show what worked or failed, saving time and preventing repeated harm. This context signals whether escalation or mediation is appropriate.

  5. What outcome would you consider fair and helpful?

    Stating a desired resolution shapes next steps and sets realistic expectations. For broader service or product issues, you might submit an Online complaint form to route it to the right team.

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