Date: Name of Grievant: Phone Number: Witness Contact Information ...

Date:

Name of Grievant:

Department:

Grievance Statement:

Received by:

GRIEVANCE FORM

Phone Number:

Witness Contact Information:

Relief Sought: STEP 1: Decision of Immediate Supervisor

____________________________________

Grievant's Signature

Date

Employee Response

Satisfied with response

Not satisfied with response

__________________________________ _______

Supervisor's Signature

STEP 2: Decision of Department Head

Date

Employee Response

Satisfied with response

Not satisfied with response

__________________________________ _______

Department Head's Signature

STEP 3: Resolution Proposed by Personnel Director

Date

Employee Response

Satisfied with response

Not satisfied with response

__________________________________ _______

Personnel Director's Signature

Please attach any documentation pertinent to the matter to this form.

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download