SECTION I - PERSONAL INFORMATION
1. NAME (Last, First, MI): is required.
2. DOD ID OR EMPLOYEE NUMBER is required.
3. Rank/Pay Grade is required.
4. CONTACT TELEPHONE NUMBER: is required.
5. ORGANIZATION (Organic Unit, Task Force, Team, etc...) is required.
6. EMAIL ADDRESS: is required.Must be a valid email address.
7. COMPONENT (e.g. TXARNG, TXANG, TXSG, State Employee). is required.
8a. Have you contacted your chain of command or any agency concerning this request (Explain for both yes and no responses.) is required. 8b. Have you contacted your chain of command or any agency concerning this request (Explain for both yes and no responses.) is required.
SECTION II - ABOUT YOUR COMPLAINT (Use continuation page if needed)
9. DESCRIPTION OF ALLEGATIONS OR ISSUES: (List the policy, rule, law, etc…, allegedly violated, misinterpreted, or misapplied) is required.
a. Describe any efforts you have made to resolve your complaint informally and the responses to your efforts. is required.
b. With whom did you communicate and on what date(s) is required.
c. What is your requested action or desired outcome to address or resolve your complaint or grievance is required.
10. I DO or DO NOT consent to release my personal information to the chain of command or other officials (but within TMD channels) in order to resolve the matters listed above. I understand that if I do not consent to the release of my personal information, my request for assistance may go unresolved. is required.
11. I DO or DO NOT consent to release the supporting documents I provided (to exclude this TMD Form) to the chain of command or other officials (but within TMD channels) in order to resolve the matters listed above. I understand that if I do not consent to the release of my documents, my request for assistance may go unresolved. is required.
SECTION IV - ACKNOWLEDGEMENT
Privacy Notice: State law requires that you be informed that you are entitled to: (1) request to be informed about the information collected about yourself on this form (with a few exceptions as provided by law); (2) receive and review that information; and (3) have the information corrected at no charge.
This information is submitted for the basic purpose of requesting assistance, correcting injustices affecting the individual, or eliminating conditions considered detrimental to the efficiency or reputation of the Texas Military Department (TMD). Those who knowingly and intentionally provide false statements on this form are subject to potential punitive and administrative action.
I certify that all of the statements made in this complaint (including any continuation pages) are true, complete, and correct to the best of my knowledge and belief. I understand that a false statement or concealment of a material fact is a punishable criminal offense.
Name: is required.
Date: is required.
SECTION V - CONTINUATION PAGE
CONTINUATION PAGE is required.