GRIEVANCE APPEAL FORM

GRIEVANT INFORMATION
GRIEVANT NAME	DATE APPEAL SUBMITTED
GRIEVANT PHONE	GRIEVANT EMAIL
GRIEVANT HOME MAILING ADDRESS	WORKPLACE MAILING ADDRESS
RECEIVED BY	DATE RECEIVED

REASON FOR APPEAL (check all that apply):
New information/evidence is now available that wasn’t considered before
The process wasn’t followed correctly
The outcome wasn’t fair and reasonable

FURTHER EXPLANATION OF REASONING use attachments if necessary

DESIRED OUTCOME 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 SIGNATURE	DATE
RECEIVED BY: PRINTED NAME AND SIGNATURE	DATE

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