1. IDENTIFICATION OF EMPLOYEE/JOB APPLICANT (COMPLAINANT)
Phone: (w) _____________________________________ (h)_________________________________________________
*Email: (REQUIRED) _________________________________________________________________________________
I am/was a certified state employee. Yes No I am/was a probationary employee. Yes No
COLORADO STATE PERSONNEL SYSTEM CONSOLIDATED APPEAL/DISPUTE FORM
This consolidated form is provided for employees and/or job applicants who are filing appeals or disputes with the State
Personnel Board or State Personnel Director. A copy of the Board Rules and Director's Administrative Procedures may
be found at http://www.colorado.gov/spb or http://www.colorado.gov/dpa.
PLEASE READ THE INSTRUCTIONS provided for completing the Consolidated Appeal/Dispute form. The form may be
printed out and filled in by hand or completed on-line and saved to your personal drive and printed out. You may attach
additional sheets if necessary, but please note which numbered question the information on the additional sheets
applies to. Pursuant to the Americans with Disabilities Act, accommodations for completing the form are available.
Contact the State Personnel Board for assistance at 303-866-3300.
Mail or hand-deliver the completed form to the State Personnel Board, 1525 Sherman Street, 4th Floor, Denver, CO
80203, or fax it to 303-866-5038. YOU MUST NOTIFY the Board or Director in writing if the information below changes
before the appeal or dispute process is concluded. NOTE: You will receive copies of Board Orders by email ONLY, and
therefore, providing an email address is mandatory. If you do not have access to email or a computer, you must request
an exemption in writing from the Board.
2. Have you retained an attorney to assist you in this matter? Yes No If so, please provide the following
information for your attorney.
4. SPECIFIC ACTION(S) BEING APPEALED OR DISPUTED and REASON(S) FOR APPEAL/DISPUTE
3. THE PARTY (DEPARTMENT/COLLEGE) WHOSE ACTION IS BEING APPEALED OR DISPUTED (RESPONDENT)
5. Were you notified in writing that this action was taken? Yes No Date you received notification. _________
If verbal, describe below. You must attach a copy of any written notification of the action that was provided to you.
Page 1 of 2, Revised 08/2014
6. RELIEF REQUESTED (What do you want as a result of this appeal?)