Assistance Request Form

Assistance Request Form

To be completed by DPI Employee
Please use this form to report an issue that you would like help resolving. Use it to ask a question, lodge a complaint, report a payroll matter, request a leave of absence, etc.
- Please be as detailed as possible.
- Attach any relevant documentation you have via the upload button below.
A DPI Representative will be in contact with you shortly. In the meantime, you may be able to find the answer through the following resources:
- Employee Website
- DPI Policies
- Anonymous Ethics Reporting Site (if you want to make a report without giving your name)
- Employee Assistance Program (for employees and their families: free counseling, training and other resources. Use "The DPI Group" as your employer when you register)
Date*

MonthDayYear
(Defaults to today’s date)
Division*
State*
Your name:*

First NameLast Name
Your email address:*
example@gmail.com
Your phone number*
Contact method preference:*

EmailTelephone call
Please select from options below to describe the nature of the issue that you would like assistance with:*

Disability Accommodation RequestWork-related problem/grievancePayroll (pay, pto, garnishment, etc)Benefits questionPolicy questionLeave of Absence requestTechnical/Avionte questionFleet/vehicle issueFacility issueSafety issue (with your worksite or DPI building)Other
What is the nature of your grievance (choose all that apply)*

Sexual HarassmentHostile Work EnvironmentADA AccommodationDiscrimination/HarassmentConflict of Interest DisclosureLegal and/or Policy ViolationRetaliationOther
Detailed description of the matter that you would like assistance with:*
When did this occur?*
If this doesn’t apply, put an “NA” in the field.
Are there any witnesses?*

YesNo
Witness Detail:
Upload any supporting documents:

Browse Files

Cancelof
Take Photo (if that would help explain or document issue):
Following the submission of this form and depending on the nature of the assistance request, you may be expected to discuss this matter with one and/or more individuals as the matter is explored/investigated.

While most assistance requests can be resolved quickly, sensitive matters will be kept as confidential as is practicable, with extra concern taken with private matters. As outlined in policy, The DPI Group (and subsidiaries) does not tolerate retaliatory actions against those who report issues and/or concerns. See employee policies 216 - Issue Reporting and 215 - Whistleblowing & Retaliation.
My signature below indicates that this is a truthful representation of the facts surrounding this report.
Signature

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