Southwest Texas Junior College Employee Complaint Form

SOUTHWEST TEXAS JUNIOR COLLEGE

EMPLOYEE COMPLAINT FORM – LEVEL FIVE

To appeal a Level Four decision or the lack of a timely response after a Level Four

conference, please fill out this form completely and submit by hand delivery, fax, or U.S.

mail to the SWTJC Board President within the time set out in SWTJC Policy DGBA

(LOCAL). Level Five appeals will be considered in accordance with DGBA (LEGAL)

and (LOCAL) or any exceptions outlined therein.

Name___________________________________________________________________

Address_________________________________________________________________

Telephone number ________________________________________________________

Employment Position ___________________Campus/Department __________________

Representative’s Name, if any _______________________________________________

Representative’s Address ___________________________________________________

Representative’s Phone Number______________________________________________

To whom did you present your complaint at Level Four? _________________________

________________________________________________________________________

Date of Level Four conference ______________________________________________

Date you received Level Four response _______________________________________

Please explain specifically how you disagree with the outcome at Level Four (use

additional pages if needed):

Attach a copy of your original complaint and any documentation previously submitted.

Attach a copy of the Level Four response being appealed, if applicable.

Employee signature________________________________________________________

Signature of Employee’s representative, if any __________________________________

Date of filing of Level Five Complaint _______________________________________

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For Administrative Use Only:

Date received________________

Level Five Complaint form received by_______________________________________

Southwest Texas Junior College Employee Complaint Form - Level One Page 6