GRIEVANCE FORM
Date: _____________________
Name of Employee: ________________________
Department: ______________________________
State your grievance in detail, including the date
of act(s) or omissions causing grievance.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Identify other employees with personal knowledge of
your grievance.
____________________________________________________________________
____________________________________________________________________
State briefly your efforts to resolve this
grievance. ____________________________
____________________________________________________________________
Describe the remedy or solution you would like. _____________________________
____________________________________________________________________
Employee's Signature: _________________________ Date: _____________
Grievance Team Member - Informal Review Date Received:
______________________
______________________________________________________________________.
Actions Taken:
_________________________________________________________
_____________________________________________________________________.
Disposition:
___________________________________________________________
Employee Accepted [ ] Employee Appealed [ ]
Assigned Team Member: _____________ Date Communicated: _____________
Grievance Team - Formal Review
Date Received:
_________________________________________________________
Actions Taken:
_________________________________________________________
______________________________________________________________________
Disposition:
___________________________________________________________
Employee Accepted [ ] Employee Appealed [ ]
Grievance Review Team:
_________________________________________________ Date Communicated: _________________________
Grievance Team and Management - Formal Review
Date Received:
_________________________________________________________
Actions Taken:
_________________________________________________________
_____________________________________________________________________
Disposition:
____________________________________________________________
Employee Accepted [ ] Employee Appealed [ ]
Management Team:
______________________________________________________ Date Communicated:
__________________________
