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APPENDIX & FORMS (Lone Star College System)

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APPENDIX & FORMS
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Formal Grievance Receipt (Form 1):
Receipt Notice Sent To:
__________________________________
Print Name
Receipt Notice Sent By:
__________________________________
Print Name
CMRRR No.: __________________________________
Certified Mail Return Receipt Request No.
Date Notice Sent: ______________________________
---------------------------------------------------------------------------------------------------------------------
Formal Grievance Notice of Conference
Please note that under our Board Policy Manual, I have ten working days to hold a conference
with you regarding your grievance. We may reschedule to a more convenient time, but a request
for a postponement beyond those ten working days is not possible unless you request a
postponement in writing as soon as practical.
I have tentatively scheduled your grievance conference for the place, date, and time below. If this
time conflicts with your schedule, or you are otherwise unable to make this appointment, please
let me know as soon as possible so we can reschedule to a more convenient time. You will receive
my decision no later than five working days after the grievance conference is actually held. If you
do not receive my decision within five working days of having a grievance conference with me,
Board Policy allows you to escalate your grievance to my supervisor,
______________________________________.
Time: _______________________
Location: _______________________
Date: _______________________
____________________________ __________________
Hearing Officer Printed Name / Title Date
__________________________
Hearing Officer Signature
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10
First Level Appeal of Grievance Request Receipt (Form 2):
Receipt Notice Sent To:
__________________________________
Print Name
Receipt Notice Sent By:
__________________________________
Print Name
CMRRR No.: __________________________________
Certified Mail Return Receipt Request No.
Date Notice Sent: ______________________________
---------------------------------------------------------------------------------------------------------------------
First-Level Appeal Notice of Conference
Please note that under our Board Policy Manual, I have ten working days to hold a conference
with you regarding your grievance. We may reschedule to a more convenient time, but a request
for a postponement beyond those ten working days is not possible unless you request a
postponement in writing as soon as practical.
I have tentatively scheduled your grievance conference for the place, date, and time below. If this
time conflicts with your schedule, or you are otherwise unable to make this appointment, please
let me know as soon as possible so we can reschedule to a more convenient time. You will receive
my decision no later than five working days after the grievance conference is actually held. If you
do not receive my decision within five working days of having a grievance conference with me,
Board Policy allows you to escalate your grievance to the Chancellor.
Time: _______________________
Location: _______________________
Date: _______________________
_____________________________ __________________
Hearing Officer Printed Name / Title Date
__________________________
Hearing Officer Signature
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11
Second Level Appeal of Grievance Request Receipt (Form 3):
Receipt Notice Sent To:
__________________________________
Print Name
Receipt Notice Sent By:
__________________________________
Print Name
CMRRR No.: __________________________________
Certified Mail Return Receipt Request No.
Date Notice Sent: ______________________________
Designee:
_________________________
---------------------------------------------------------------------------------------------------------------------
Second-Level Appeal Notice of Conference
Please note that under our Board Policy Manual, I have ten working days to hold a conference
with you regarding your grievance. We may reschedule to a more convenient time, but a request
for a postponement beyond those ten working days is not possible unless you request a
postponement in writing as soon as practical.
I have tentatively scheduled your grievance conference for the place, date, and time below. If this
time conflicts with your schedule, or you are otherwise unable to make this appointment, please
let me know as soon as possible so we can reschedule to a more convenient time. You will receive
my decision no later than five working days after the grievance conference is actually held. If you
do not receive my decision within five working days of having a grievance conference with me,
Board Policy allows you to escalate your grievance to the Board of Trustees so long as you alleged
a specific procedural irregularity that violates a specific, enumerated Board Policy via Grievance
Form 4.
Time: _______________________
Location: _______________________
Date: _______________________
_______________________________ _________________
Hearing Officer Printed Name / Title Date
__________________________
Hearing Officer Signature
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12
Request for Board Appeal of Grievance (Form 4):
Grievant:
__________________________________
Print Name
__________________________________
Signature
Specific Board Policy Allegedly Violated: _____________________________
(Please reference specific policy sections) _____________________________
Please remember to attach a summary of the basis for your appeal.
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Grievance History Form (Form 5)
Formal Grievance (Part I)
Grievant/Grievant-in-Charge Name: __________________________________________________________
Date Received: ______________________________ Notice of Receipt Sent: _______________________
(Within 3 working days of receipt)
Campus/Location: ___________________________ Conference Date: ____________________________
(Within 10 working days of receipt)
Division: ____________________________________
To be completed by the Grievance Conference Officer
Date of Conference: _________________ Time: ___________________
Location:_______________________
Decision Due Date: __________________ Notice of Appeal Deadline:____________________
(Within 5 days of the Conference)
Decision Date: ______________________ Signature: __________________________________
--------------------------------------------------------------------------------------------------------------------------------------------
First-Level Appeal (Part II)
Date Received: ___________________________ Notice of Receipt Sent: _______________________
(Within 3 working days of receipt)
Summary Sent to the Chancellor: _______________________
(Within 3 working days of receipt)
Appeal Conference Date: ______________________
(Within 10 working days of receipt)
To be completed by the Appeals Conference Officer
Date of Conference: ___________________ Time: ___________________
Location:_______________________
Deadline for Additional Information from Grievant: ______________________________
(Within 3 working days of the Conference)
Decision Due Date: _______________ Notice of Appeal Deadline:______________
(Within 5 working days of the Conference) (Within 10 working days of the Decision/Decision Due Date)
PAGE 1 OF 2
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Second-Level Appeal (Part III)
Date Appeal Received: _______________________ Notice of Receipt: _______________________
(Within 3 working days of receipt)
Appeal Conference Date: _______________
(Within 10 working days of receipt) Summary Sent to the Board: ______________
(
Within 3 working days of receipt)
To be completed by the Chancellor/Designee
Date of Conference: ___________________ Time: ___________________
Location:_______________________
Deadline for Additional Information from Grievant: ______________________________
(Within 3 working days of the Conference)
Decision Due Date: _______________ Notice of Appeal Deadline:______________
(Within 5 working days of the Conference) (Within 10 working days of the Decision/Decision Due Date)
--------------------------------------------------------------------------------------------------------------------------------------------
Appeal to the Board (Part IV)
Date Received: ______________________ Time: ____________________
Location: __________________________
Notice of Receipt to Grievant: ______________________
(Within 5 working days of receipt)
Information Forwarded to the Board: _________________
(Within 5 working days of receipt)
Board Appeal Conference Date: ________________
(Next Board Meeting at Least 15 Days Away)
To be completed by the Board Chair
Date of Hearing: ______________________ Time: ___________________
Location: ____________________________
Decision Due Date: _______________________
(Within 30 working days of Appeal Conference Date)
Signature: _____________________________
PAGE 2 OF 2
14
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APPENDIX & FORMS (Lone Star College System)

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Completed 6 October 2020

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