EMPLOYEE GRIEVANCE FORM

GRIEVANT INFORMATION
EMPLOYEE NAME	DATE FORM SUBMITTED
JOB TITLE	EMPLOYEE ID
EMPLOYEE HOME MAILING ADDRESS	WORKPLACE MAILING ADDRESS

DETAILS OF EVENT LEADING TO GRIEVANCE
DATE, TIME, AND LOCATION OF EVENT	WITNESSES if applicable
ACCOUNT OF EVENT	VIOLATIONS
Provide a detailed account of the occurrence. Include the names of any additional persons involved.	Provide a list of any policies, procedures, or guidelines you believe have been violated in the event described.

PROPOSED SOLUTION

Please retain a copy of this form for your own records. As the grievant, please provide your signature below, as it indicates that the information you've included on this form is truthful.

SIGNATURES
EMPLOYEE SIGNATURE	DATE
RECEIVED BY: PRINTED NAME AND SIGNATURE	DATE

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