Fillable COLORADO STATE PERSONNEL SYSTEM CONSOLIDATED APPEAL/DISPUTE FORM (Metropolitan State College of Denver)

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COLORADO STATE PERSONNEL SYSTEM CONSOLIDATED APPEAL/DISPUTE FORM (Metropolitan State College of Denver)

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The COLORADO STATE PERSONNEL SYSTEM CONSOLIDATED APPEAL/DISPUTE FORM (Metropolitan State College of Denver) form is 2 pages long and contains:

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1. IDENTIFICATION OF EMPLOYEE/JOB APPLICANT (COMPLAINANT)
Name: _____________________________________________________________________________________________
Address:____________________________________________________________________________________________
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.
Name: _______________________________________________________________________________________________
Address:______________________________________________________________________________________________
Phone: _______________________________________________________________________________________________
Fax: _________________________________________________________________________________________________
*Email: (REQUIRED)____________________________________________________________________________________
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)
Name: _______________________________________________________________________________________________
Department:___________________________________________________________________________________________
Address:______________________________________________________________________________________________
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?)
7.
TYPE OF APPEAL OR DISPUTE: Check all that apply.
Administrative Discharge (
Administrative discharge applies to exhaustion of leave)
Disciplinary Action (Termination or anything that affects your base pay, status or tenure)
Discrimination - Based on:
Age Political Affiliation
Disability Race/Color
Gender Religion/Creed
Sexual Harassment Sexual Orientation
National Origin/Ancestry Veteran's Status
Organizational Membership Other: ______________________________
_________________________________________________________________________________________
Whistleblower
(Retaliation for disclosure of information concerning waste of public funds, abuse of authority or mismanagement of any state
agency). YOU MUST ATTACH A SEPARATE COMPLAINT FORM WHICH MAY BE FOUND AT:
http://www.colorado.gov/spb/forms.
Downward Position Allocation Appeal (Allocation to a class in a lower pay grade)
Forced Resignation
Final Grievance Decision: The final agency grievance decision violates the following (YOU MUST CHECK ALL THAT APPLY AND
ATTACH A COPY OF THE FINAL GRIEVANCE DECISION:
Discrimination Grievance Procedures (Board Rule 8-8 or agency process
Federal or State Constitutional Rights Whistleblower
Layoff
Director's Review (Overtime; FMLA; removal of name from eligible list; rejection of job application; an action involving the overall
administration of the personnel system by an agency which cannot otherwise be appealed)
8. SIGNATURE: THIS FORM MUST BE SIGNED BY COMPLAINANT OR, IF APPLICABLE, COMPLAINANT'S REPRESENTATIVE.
SIGNATURE BY COMPLAINANT'S REPRESENTATIVE CONSTITUTES AN ENTRY OF APPEARANCE FOR AN APPEAL. ALL
DOCUMENTS AND CORRESPONDENCE WILL BE SENT TO THE PERSON SIGNING THIS FORM.
_________________________________ ________________________________________________
Date Signature of Complainant
9. CERTIFICATE OF DELIVERY: YOU MUST HAND-DELIVER OR MAIL A COPY OF YOUR APPEAL TO THE
RESPONDENT LISTED IN #3.
I certify that I have served a copy of this appeal on Respondent at the address listed in #3
above by:
First Class Mail ___ Hand-Delivery ___ this ___ day of __________________, 20__.
_______________________________________
Signature of Complainant
Performance Management Dispute (Disputable matters include individual final overall performance evaluation, the application of
the department's performance management program, or the lack of a final overall evaluation. (Attach a copy of the original internal dispute
and the department's decision and submit within 5 business days of the department's decision)
Decision to Exempt a Position from the State Personnel System
Selection Appeal Alleging Discrimination
Page 2 of 2, Revised 08/2014
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COLORADO STATE PERSONNEL SYSTEM CONSOLIDATED APPEALDISPUTE FORM (Metropolitan State College of Denver)

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Completed 18 September 2020

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