Revised: 1-22-10
Please submit all grievances in accordance with the procedure contained in Chapter IX of the County Personnel Policy Manual. A copy of the
procedure may be obtained from the Human Resource Department.
Step Number: __________
Employee's Name: ____________________________________ Department: ____________________________________
Submitted To: ________________________________________ Title: __________________________________________
Reason for Grievance:
Termination Suspension Demotion Harassment Discrimination Unfair Application of Benefits
Other Adverse Employment Action (Specify) _________________________________________________________________
Employment Conditions (Specify) __________________________________________________________________________
Employee's Statement
Please provide a detailed statement including dates, times, location, and names of witnesses or other parties who may have relevant
information to contribute. Attach copies of any documents or statements which you wish to be considered and indicate what you
feel would be a fair and equitable solution or response to your grievance. Attach copies of any statements or responses from
previous steps in the grievance process. (attach additional pages if needed)
Signature: __________________________________________________ Date Submitted: ______________________
Received by: ______________________________________________ Date Received: _______________________