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Grievance

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					                                                Grievance Form



Step 1 (To be completed by employee)

        Employee’s Name:
        Job Title:
        Department Name:

        Immediate Supervisor’s Name:
        Date of Alleged Violation:
        Human Resources Policy, Rule or Procedure Violated by the County:




        Statement of Grievance (This action or situation about which you have a dispute or difference.
        Be specific, give names, dates, locations, etc.):




        Your Suggested Remedy:




        Employee’s Signature:

        Date Grievance Presented to Supervisor:

        Was this problem discussed with your Immediate Supervisor prior to filing this
        grievance?

            Yes      Date:                            No
                                                                                           Revised 9/7/2007
                                                                                                Page 1 of 4
To be completed by Immediate Supervisor

 Receiving Supervisor’s Signature:

 Date Grievance Received:

 Did you review this grievance with the above employee?    Yes              No

 Immediate Supervisor’s Answer:




Employee’s Signature Acknowledging Answer:

Date Employee Received Answer:

Grievance is Settled
                             (Employee Signature)                  (Date)


- OR -

Grievance is unsettled and I wish to appeal to Step 2.


          (Employee Signature)                            (Date)




                                                                                 Revised 9/7/2007
                                                                                      Page 2 of 4
Step 2 (To be completed by Department Director)


       Receiving Department Director’s Signature:

       Date Grievance Received:

       Date of Step 2 Conference:

       Date Employee Advised of Conference:

       Department Director’s Answer:




       Department Director’s Signature

       Date:


       Employee’s Signature Acknowledging Answer:

       Date Employee Received Answer:

       Grievance is settled
                                   (Employee Signature)                  (Date)

       - OR -

       Grievance is unsettled and I wish to appeal to Step 3.


                (Employee Signature)                            (Date)




                                                                                  Revised 9/7/2007
                                                                                       Page 3 of 4
Step 3 (To be completed by Peer Review Committee)


       Date Grievance Received:

       Date of Step 3 Hearing:

       Date Employee Advised of Hearing:

       Peer Review Committee Members:




       Peer Review Committee’s Factual Determinations and Recommendation:




       County Administrator’s Decision:




       County Administrator’s Signature:

       Date


       Received by Employee:
                                      (Employee Signature)          (Date)




                                                                             Revised 9/7/2007
                                                                                  Page 4 of 4

				
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