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Reference To Adjudication

Règlement et règles de procédure de la C.R.T.F.P. (1993)

FORM 14

(Subsection 76(1))

Public Service Staff Relations Act

REFERENCE TO ADJUDICATION

Before the Public Service Staff Relations Board

PART I - TO BE COMPLETED IN ALL CASES

I, the undersigned, hereby refer a grievance to adjudication under section 92 of the Public Service Staff Relations Act. The

particulars are as follows:

LAST OR FAMILY NAME

FIRST AND OTHER NAMES

(print in block letters)

(underline name used)

Mr./Mrs./Miss/Ms.

HOME ADDRESS

PHONE NO.

(no., street, city, province)

(a) office

(b) home

EMPLOYER

LOCATION

BRANCH OR DIVISION

SECTION OR UNIT

JOB TITLE

10.

JOB CLASSIFICATION

11.

(1) Date on which the grievance was presented at the first level of the grievance process:

(2) Date on which the grievance was presented at the final level of the grievance process:

12.

Date on which the employer provided you with a reply at the final level of the grievance process:

13.

Name and address of adjudicator, if any, named in collective agreement:

14.

Name and address of adjudicator, if any, selected by the parties:

PLEASE ATTACH A COPY OF THE ORIGINAL GRIEVANCE

15.

Indicate the provision of subsection 92(1) of the Act under which you are referring your grievance to adjudication by

checking the appropriate box below. If no box is checked or if more than one box is checked, processing of this

reference may be delayed.

92(1)(a)

92(1)(b)(i)

92(1)(b)(ii)

92(1)(c)

PART II -

To be completed in all cases where the grievance is referred to adjudication pursuant to subparagraph 92(1)(b)(i)

or (ii) or paragraph 92(1)(c) of the Act.

NOTE:

You do not require the approval or support of your bargaining agent, if any, on a grievance that does not relate

to the interpretation or application of a provision of a collective agreement or an arbitral award. However, you

Reference To Adjudication

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