Formal Grievance Form
Please type or print clearly using ink. All grievances under the Civil Service System will
be resolved as quickly as possible and at the lowest administrative level possible without
regard to race, color, religion, sex, national origin, age, or disability.
Human Resources/Civil Service Department
509 Main Street, Room 103
Dallas, Texas 75202
Dallas County Formal Grievance Form
Employee Name: Department:
State, Zip Code
Home Telephone Number: Work Telephone:
Mobile Telephone Number: Email Address:
SCOPE OF GRIEVANCE APPEAL PROCEDURES
A Grievance may be filed on one or more of the following grounds. Indicate the basis for your grievance and
consult Section 86-1001 through 86-1007 of the Dallas County Code for additional information.
ο □ Improper applications of rules, regulations, and procedures
ο □ Unfair treatment, including coercion, restraint or reprisal
ο □ Discrimination based on race, religion, color, creed, gender, age, national origin, disability or political
affiliation (circle specific item grieved)
ο □ Disciplinary action taken without proper cause
ο □ Improper application of fringe benefits or improper working conditions (circle specific item grieved)
ο □ Demotion, suspension or dismissal (circle specific item grieved)
REASON(S) FOR GRIEVANCE
State your grievance in detail, including the date(s) of acts or omissions causing the grievance. Indicate the
specific rule or benefit not properly applied and why you believe the disciplinary action taken is unjust or unfair.
Attach additional sheets if necessary.
Identify other employees who may have witnessed this grievance.
Describe the remedy or solution being requested by the filing of this grievance.
ATTORNEY OR THIRD PARTY
State, Zip Code
Employee Signature: Date:
A grievance must be filed in writing within seven calendar days from its occurrence and/or from the date of
receipt of written notification of disciplinary action, exclusive of holidays, to be considered.
Termination and disciplinary action grievances should be initially filed with the first level of supervision above the
employee’s supervisor who has caused the action, with a copy to the employee’s immediate supervisor and the
Human Resources/Civil Service Department.
All other grievances should be initially filed with the employee’s immediate supervisor.
Internal Use Only
Date Appealed (1st)
Date Appealed (2nd)
Date Appealed (3rd)