GRIEVANCE FORM

NAME OF MEMBER _______________________________________________________

DEPARTMENT __________________________________________________________

FACULTY/SCHOOL _______________________________________________________

Does this dispute involve a claim of unjust treatment or a grievance? Please place a check in the appropriate box.

___    UNJUST TREATMENT    ___    GRIEVANCE

NATURE OF DISPUTE ____________________________________________________

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FACTS ________________________________________________________________

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REMEDY SOUGHT ________________________________________________________

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RESULT OF INFORMAL STAGE _____________________________________________

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IF A GRIEVANCE, STATE THE SECTION(S) OF AGREEMENT YOU CLAIM HAVE BEEN VIOLATED.

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SIGNATURE OF MEMBER    DATE

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SIGNATURE OF ASSOCIATION REPRESENTATIVE    DATE

ALL GRIEVANCES MUST BE SIGNED AND DATED BY THE DEAN/DIRECTOR ON THE DATE PRESENTED.

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SIGNATURE OF DEAN/DIRECTOR    DATE

Questions or Comments? Contact Josie Lubega at (204) 474-8288