Cs Form 6a - Employee Grievance Form - Hillsborough County Civil Service Page 2
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2Hillsborough County Civil Service
Employee Grievance Form
CS Form 6A
Section 1:
To: ________________________________________________
___________________________________
(Today’s Date)
(Immediate Supervisor)
NOTE: To be acceptable, a grievance must be filed within five (5) working days, or seven (7)
___________________________________
calendar days following the occurrence of the incident, or the series of related incidents.
(Date of Incident)
Section 2:
In accordance with Civil Service Rule 14, I respectfully request your consideration in resolving the matter as
described below.
I believe this grievance matter is in violation of the following Civil Service
___________________________________
Law or Rule(s) and/or Appointing Authority Policy(s):
STATEMENT OF GRIEVANCE: (Please attach additional pages if necessary) _________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
______
What do you think should be done to resolve this grievance? (Please attach additional pages if necessary)
________________________________________________________________________________
________________________________________________________________________________
___________________________
___________________________
(Employee’s Signature)
(Employee’s Printed/Typed Name)
______
Number of Attachments
I
mmediate Supervisor Response:
___________________________________
To: ________________________________________________
(Today’s Date)
(Employee/Grievant)
NOTE: The immediate supervisor must respond no later than five (5) working days, or seven
___________________________________
(7) calendar days, whichever is sooner.
(Date of Receipt)
I have reviewed the grievance as described above and offer the following comments: (Please attach additional
_________________________________________________________
pages if necessary)
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Should this remedy not meet your expectations, you are hereby advised that in accordance with Civil Service
______________________
Rule 14, you may present this matter to
for his/her consideration.
(Second-Line Supervisor)
___________________________
___________________________
(Immediate Supervisor’s Signature)
(Immediate Supervisor’s Printed/Typed Name)
___________________________
______
Number of Attachments
(Immediate Supervisor’s Title)
Section 3:
To: ________________________________________________
___________________________________
(Immediate Supervisor)
(Today’s Date)
I accept your solution to the grievance as presented.
___________________________
NOTE : If you do NOT accept your immediate supervisor’s solution you may
(Employee’s Signature)
forward your grievance on CS Form 6B to your second-line supervisor.
CS Form 6A
(5/05)
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