Form I-766 - Personnel System Consolidated Appeal/dispute Form - State Of Colorado Page 2
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1
2TYPE OF APPEAL OR DISPUTE
7.
: Check all that apply.
Administrative Discharge (
)
Administrative discharge applies to exhaustion of leave
Disciplinary Action (
)
Termination or anything that affects your base pay, status or tenure
Discrimination - Based on:
Age
Political Affiliation
Disability
Race/Color
Gender
Religion/Creed
Sexual Harassment
Sexual Orientation
National Origin/Ancestry
Veteran's Status
Organizational Membership
Other: ______________________________
_________________________________________________________________________________________
Whistleblower
(
Retaliation for disclosure of information concerning waste of public funds, abuse of authority or mismanagement of any state
agency). YOU MUST ATTACH A SEPARATE COMPLAINT FORM WHICH MAY BE FOUND AT:
.
Decision to Exempt a Position from the State Personnel System
Downward Position Allocation Appeal
(Allocation to a class in a lower pay grade)
Forced Resignation
Layoff
Selection Appeal Alleging Discrimination
Final Grievance Decision:
The final agency grievance decision violates the following (YOU MUST CHECK ALL THAT APPLY AND
ATTACH A COPY OF THE FINAL GRIEVANCE DECISION:
Discrimination
Grievance Procedures (Board Rule 8-8 or agency process
Federal or State Constitutional Rights
Whistleblower
Director's Review
(Overtime; FMLA; removal of name from eligible list; rejection of job application; an action involving the overall
administration of the personnel system by an agency which cannot otherwise be appealed)
Performance Management Dispute (
Disputable matters include individual final overall performance evaluation, the application of
the department's performance management program, or the lack of a final overall evaluation. (Attach a copy of the original internal dispute
and the department's decision and submit within 5 business days of the department's decision)
8. SIGNATURE:
THIS FORM MUST BE SIGNED BY COMPLAINANT OR, IF APPLICABLE, COMPLAINANT'S REPRESENTATIVE.
SIGNATURE BY COMPLAINANT'S REPRESENTATIVE CONSTITUTES AN ENTRY OF APPEARANCE FOR AN APPEAL.
ALL
DOCUMENTS AND CORRESPONDENCE WILL BE SENT TO THE PERSON SIGNING THIS FORM.
_________________________________
________________________________________________
Date
Signature of Complainant
CERTIFICATE OF DELIVERY
9.
:
YOU MUST HAND-DELIVER OR MAIL A COPY OF YOUR APPEAL TO THE
I certify that I have served a copy of this appeal on Respondent at the address listed in #3
RESPONDENT LISTED IN #3.
above by:
First Class Mail ___ Hand-Delivery ___ this ___ day of __________________, 20__.
_______________________________________
Signature of Complainant
Page 2 of 2, Revised 08/2014
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