Employee Disciplinary Action Appeal Form And Request For Board Of Review Form
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1
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3Employee Disciplinary Action Appeal Form
And
Request for Board of Review Form
This form must be completed when an employee initiates an appeal from a disciplinary action or other
eligible issue as listed in the Administrative Procedures and Board of Review Policies.
The appeal must be filed within 7 days of the receipt of a disciplinary action or within 7 days of the
occurrence of an eligible issue to be considered timely. At each step in the appeal process, the
employee will have 7 days from the notice of management’s action to move his or her appeal to the next
step. Failure of the employee to submit his or her appeal within 7 days is considered a waiver or
withdrawal of the appeal.
IF YOU HAVE ANY QUESTIONS ABOUT THIS PROCESS OR POLICY, CONTACT HUMAN RESOURCES
BEFORE YOUR 7 DAYS HAVE EXPIRED.
Name: _________________________________________ Department: _________________________
Job Title: _______________________________________ Work Location: _______________________
Work Phone: ____________________________________ Cell Phone: ___________________________
Email: _______________________________________________________________________________
1
st
Level Appeal (Department Head Appeal)
(put drop down here of list)
Date of Disciplinary Action: _____________ Eligible Issue Being Appealed
Supervisor Who Issued Discipline: ____________________________________
What is the nature of your claim, dispute or complaint? ( Please state facts and be specific as to the date, place
and individuals involved. Attach additional pages as necessary .)
State your understanding of the discipline issued.
What specific solution or resolution are you requesting?
In accordance with the Administrative Procedures Policy, I choose to file this appeal with my Department
Head.
PINE CREEK INDIAN RESERVATION
1485 MNO-BMADZEWEN WAY • FULTON, MI 49052
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