Form 27916 - Merit Employee Complaint
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1MERIT EMPLOYEE COMPLAINT
Indiana State Personnel
State Form 27916 (R7 / 1-08)
Department
OFFICE USE ONLY
Complaint #
Instructions:
Please complete all required information and state exact nature of complaint and desired remedy
PRINT OR TYPE LEGIBLY
Steps in complaint procedure are on reverse side.
Full name of employee
Name of agency
Contact telephone #
Home address (number & street, city, state, ZIP code)
Employee ID#
Last 4 digits of Social Security Number
Classification Title
Job Code
STEP 1
Date of discussion with immediate
*The oral answer of the immediate supervisor must be given within
Initials of Supervisor
supervisor
two (2) consecutive working days from date of discussion.
STEP 2
Statement of Complaint (Attach additional pages if necessary)
Signature of employee
Date complaint form was presented to
*Answer of intermediate supervisor (must be given in writing within four (4) consecutive
intermediate supervisor
working days).
Signature of intermediate supervisor
Date
Signature of employee if Step 2 answer is satisfactory
Date of receipt of Step 2 response
STEP 3
Date complaint form was presented to
*
Decision of appointing authority (must be given within ten (10) consecutive working
appointing authority
days).
Signature of appointing authority
Date
Signature of employee if Step 3 response is satisfactory
Date of receipt of Step 3 response
*If management fails to respond in prescribed time, employee may elect to process appeal to the next step. If employee wishes to pursue complaint
beyond Step 3, completed complaint form must be submitted to the State Personnel Director within fifteen (15) calendar days from receipt of written Step
3 decision.
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