Name of Employee

Department

State your grievance in detail, including the date of acts(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

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