Grievance Procedure Form
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1GRIEVANCE P ROCEDURE F ORM
If the complaint is not resolved after making full use of the informal procedure, the employee must submit
Grievance Form I to the Appropriate Office and submit a copy to his/her immediate supervisor for further
action to be taken.
Employee’s Name
Phone No.
Department/Division
Supervisor
On what date(s) did incident(s) occur?
GRIEVANCE: (Please explain why you are filing this grievance. Use additional paper if needed)
*Specify the policy or procedure supporting your contention:
Please indicate why, in your opinion, the informal procedure did not resolve your grievance:
What resolution/remedy are you requesting:
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MPLOYEE
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IGNATURE
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