GOVERNMENT GRIEVANCE FORM

GRIEVANT INFORMATION
EMPLOYEE NAME	DATE FORM SUBMITTED
JOB TITLE	DATE GRIEVANCE OCCURRED
WORK TELEPHONE NO. with EXT.	HOME TELEPHONE NO.
WORK EMAIL ADDRESS	HOME EMAIL ADDRESS
WORKPLACE MAILING ADDRESS	HOME MAILING ADDRESS

GOVERNMENT AGENCY INFORMATION
AGENCY NAME	FACILITY NAME
GRIEVANT IMMEDIATE SUPERVISOR NAME AND TITLE	GRIEVANT IMMEDIATE SUPERVISOR PHONE AND EMAIL

Grievances must be submitted within 30 calendar days of the date the employee knew or should have known of the issue being grieved.
Check if you decided not to present this grievance to your immediate supervisor because (check one):
Discrimination or Retaliation by Immediate Supervisor
Grieving disciplinary action issued by someone other than Immediate Supervisor

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

PROPOSED SOLUTION use attachments if necessary

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

SIGNATURES

GRIEVANT NAME	GRIEVANT SIGNATURE	DATE
RECEIVER NAME	RECEIVER SIGNATURE	DATE

SUBMISSION PROCESS
COMPLETED FORMS SHOULD BE SUBMITTED TO	IN THE CASE OF BYPASSING IMMEDIATE SUPERVISOR, PLEASE SUBMIT COMPLETED FORM TO

RESOLUTION STEP 1 – RESPONDENT
STEP 1 RESPONDENT NAME	DATE RECEIVED
STEP 1 RESPONDENT PHONE with EXT.	STEP 1 RESPONDENT EMAIL
RESPONSE use attachments if necessary

STEP 1 RESPONDENT SIGNATURE	DATE

RESOLUTION STEP 1 – GRIEVANT
GRIEVANT NAME	DATE RECEIVED
GRIEVANT COMMENTS OPTIONAL use attachments if necessary

The employee is responsible for having the grievance delivered to the proper person or office within five workdays.
GRIEVANT RESPONSE (check one):
I conclude my grievance and am returning it to the Human Resources Office.
I advance my grievance to Step 2.

GRIEVANT SIGNATURE	DATE

RESOLUTION STEP 2 – RESPONDENT
STEP 2 RESPONDENT NAME	DATE RECEIVED
STEP 2 RESPONDENT PHONE with EXT.	STEP 2 RESPONDENT EMAIL
RESPONSE use attachments if necessary

STEP 2 RESPONDENT SIGNATURE	DATE

RESOLUTION STEP 2 – GRIEVANT
GRIEVANT NAME	DATE RECEIVED
GRIEVANT COMMENTS OPTIONAL use attachments if necessary

The employee is responsible for having the grievance delivered to the proper person or office within five workdays.
GRIEVANT RESPONSE (check one):
I conclude my grievance and am returning it to the Human Resources Office.
I advance my grievance to Step 3.

GRIEVANT SIGNATURE	DATE

RESOLUTION STEP 3 – RESPONDENT
STEP 3 RESPONDENT NAME	DATE RECEIVED
STEP 3 RESPONDENT PHONE with EXT.	STEP 3 RESPONDENT EMAIL
RESPONSE use attachments if necessary

STEP 3 RESPONDENT SIGNATURE	DATE

RESOLUTION STEP 3 – GRIEVANT
GRIEVANT NAME	DATE RECEIVED
GRIEVANT COMMENTS OPTIONAL use attachments if necessary

The employee is responsible for having the grievance delivered to the proper person or office within five workdays.
GRIEVANT RESPONSE (check one):
I conclude my grievance and am returning it to the Human Resources Office.
I advance my grievance to the next step and request qualification of my grievance for hearing.

GRIEVANT SIGNATURE	DATE

QUALIFICATION FOR HEARING – AGENCY HEAD
AGENCY HEAD	DATE RECEIVED
AGENCY HEAD PHONE with EXT.	AGENCY HEAD EMAIL

QUALIFICATION FOR A HEARING (check one):
Grievance is qualified in full.
Grievance is qualified only in part, as described by agency head below (or in an attachment).
Grievance is not qualified.

REASONS use attachments if necessary

AGENCY HEAD SIGNATURE	DATE

QUALIFICATION FOR HEARING – GRIEVANT
GRIEVANT NAME	DATE RECEIVED
GRIEVANT COMMENTS OPTIONAL use attachments if necessary

This form must be returned to the Human Resources Office within five workdays after receipt of the agency head’s qualification decision. The agency will retain the original.
GRIEVANT RESPONSE (check one):
I conclude my grievance and am returning it to the Human Resources Office.
I appeal the agency head’s qualification decision and ask the Human Resources Office to forward the grievance record to:
[If partial qualification] I waive any further right of appeal on any unqualified issues and ask the agency to request appointment of a hearing officer.

GRIEVANT SIGNATURE	DATE

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