TERO Intake/Compliant Form

T.E.R.O. INTAKE (Title 10-1-2)
Any person, group of persons, or organization including any employee of the T.E.R.O. that believes any covered employer or entity has violated any requirements imposed by this code, or regulations adopted under it, may file a complaint with the T.E.R.O. The complaint shall be in writing, shall be signed under oath by the complainant, and shall provide such information as is necessary to enable the T.E.R.O. to carry out an investigation.

Name of Charging Party (Plaintiff)

First Name

Last Name

Tribal Affiliation

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Physical Location

Your Main Phone Number

(###)

###

####

Name of Party Charges are being filed against (Defendant)

First Name

Last Name

Position

Manager

Business Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Business Phone Number

(###)

###

####

Site/work Location (If applicable)

Type of employer/Employment

Source Funding (Program)

Contract Award No (If applicable)

Date Released

YYYY

Monitoring Agency

Current Position & Rate of Pay (if applicable)

Length of Time in Current Position

Month/Day/Year TO Month/Day/Year

Immediate Supervisor

Title of Immediate Supervisor

Tribal Affiliatioin

Person with Hiring Authority

Title of Person with Hiring Authority

Tribal Affiliation

What action was taken against you that you believe to be a violation of Colville Tribal Code, Title 10 or any other rules and regulations of the T.E.R.O.?Please provide Names, Dates, Times, Etc.

Have you been aided or assisted by any other agency, attorney, or official Representing the tribe? If yes, please list below

Name, Title/Position, Mailing Address, Telephone

Please Provide the Names fo any WITNESSES that may have first hand knowledge and information concerning this specific complaint

Name, Title/Position, Mailing Address, Telephone

Type of Charge

Colville Tribal Code - Title 10

Do you hereby authorize the release of employment rocord to T.E.R.O. office, or any other agency/individual having information pertaining to my grievance. This form is covered by the Privacy Act of 1972: PL 93-579 and the Colville Tribal Code - Title 85 (Title 10-2). Futheremore, I believe this information and all statements mad eto be true and correct to the best of my knowledge.

Release of Information

Yes