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Employee Feedback Form
My Name:
*
First
Last
Today's Date:
*
MM slash DD slash YYYY
Feedback Type
*
Please Choose an Option Below
Concern Between Employees
General Concern
General Feedback
Positive Shout Out
Feedback Involves:
*
(If your concern is not about a specific employee or customer choose N/A)
An Employee
A Customer
N/A
Name of My Employee Affected:
*
First
Last
Name of Employee Subject to the Concern
*
First
Last
Employee Type
*
Please Choose an Option Below
Sales Employee
Office Employee
Sales Rep Type
*
Please Choose an Option Below
Field
DIS
TIS
Department
*
Please Choose an Option Below
Fulfillment
Sales Support
DIS Operations
Marketing
Customer Support
Accounting
Payroll
HR
IT
Recruiting
Name of Employee:
*
First
Last
Positive Shout Out Details:
*
Product(s) Affected:
*
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Business Name:
*
Business Location
*
City
Alabama
Alaska
American Samoa
Arizona
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California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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Hawaii
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Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
Nevada
New Hampshire
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New York
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Northern Mariana Islands
Ohio
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Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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Armed Forces Europe
Armed Forces Pacific
State
Business Address (If Applicable)
Street Address
Address Line 2
ZIP Code
Date of Contract (If Known):
MM slash DD slash YYYY
Product(s) Affected:
*
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OPTIMA™
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Positive Shout Out Details:
*
Incident Information
Date of Incident:
*
MM slash DD slash YYYY
Time of Incident:
*
:
Hours
Minutes
AM
PM
AM/PM
Location of Incident (If Applicable)
Please Choose an Option Below
Over the Phone
Zoom Meeting
In Person
Which best describes your feedback/concern?
*
Please Choose an Option Below
Timeliness of Work/Response Time to Results
Accuracy of Work
Product Knowledge
Misrepresenting Product
Internal Professionalism with Employees
External Professionalism with Customers
Other
Other:
*
Please describe any details of the situation:
*
Attach Files
Please Attach Supporting File, Screenshot or Email (If Applicable)
Drop files here or
Select files
Accepted file types: jpg, png, pdf, Max. file size: 180 MB, Max. files: 10.
Is this the first time you have raised this concern about this person or customer?
*
Yes
No
Please describe or provide additional explanation:
*
Was the situation resolved?
*
Please choose an option below
Yes
No
What was the Resolution?
*
Please Choose an Option Below
Customer Cancellation
Rep Chargeback
Customer Refund
Talk to Manager
Other
Other
*
If the situation was not resolved do you have any suggestions for a resolution? If so, please explain:
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