Employee Complaint Form

TKH Corporate Complaint/Notification Form	Complete and Print a Form in PDF Format
Employee and Non-Employee Confidential Reporting Form

Please complete the following form to begin the process of registering an alleged violation of Policy or Law in accordance with the TKH Corporate Governance Policy. The Complaint Form shall be sent to the Corporate Audit Committee as an attachment PDF Document to TKHComplianceCommittee@takata.com , mailed to the Committee at the address printed on the second page of this document, or left in the confidential drop-box in each location.If mailing, simply staple both pages of the complaint form, fold in thirds, attach postage and mail. The Company assures you that confidentially registering an alleged violation of Policy or the Law will not result in any retaliation and will not threaten your job in any way.

EMPLOYEE INFORMATION
If you wish to remain anonymous,simply complete the Company name, job title, location and department information below. Add a unique identifying code in place of your name for the purpose of monitoring the investigation process. You may use the unique number to identify yourself in the future regarding this claim.

Employee Number:		Employee Name:
Job Title:		Company Name:
Location:		Department:

NON-EMPLOYEE INFORMATION
If you wish to remain anonymous,simply add a unique identifying code in place of your name for the purpose of monitoring the investigation process. You may use the unique number to identify yourself in the future regarding this claim.

Name:		Company Affiliation:
Address:		City, State, Postal Code and Country:
Phone Contact:

NOTIFICATION OF RECEIPT AND ONGOING INVESTIGATION RESULTS
Do you wish to be notified upon the Committee’s receipt of this complaint?	Yes No
Do you wish to be notified of the results of the Committee’s investigation and findings?	Yes No

If you wish to be notified, please let us know where you can be reached, either by phone, mailing address or EMAIL address. All information will be kept confidential. When addressing you by phone, mailing address or EMAIL address, the Company will refer to you by the identification code provided above, if you’ve chosen to provide one.


Phone:	EMAIL:	Mailing Address:

NATURE OF THE COMPLAINT
Attach Additional Pages as Necessary
In as many words as necessary, please describe the alleged violation of Company Policy or Law which is of concern. Detailed information regarding the place of occurrence, time, date(s), persons involved and the specific facts will help the Committee to investigate your claim(s).

Date: