Revised date 2016-10-14
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7. TYPE OF APPEAL OR DISPUTE:
Colorado State Personnel Board
Check all boxes that apply
If you are claiming discrimination or retaliation check all that apply:
Disability
Gender
Sexual Harassment
National Origin/Ancestry
Organizational Membership
Race / Color
Religion / Creed
Sexual Orientation
Veteran’s Status
Other: ______________________________________________
Disciplinary Action: you have received an adverse
action that affects your base pay, status, or tenure.
Decision to exempt a position from the State Personnel System: you are
appealing the final decision made by State Personnel Director.
Forced Resignation: you reasonably believe you were
coerced or forced to resign your employment.
Whistleblower: you were retaliated against for disclosure of information
concerning waste of public funds, abuse of authority, or mismanagement of a
state agency. You must attach a separate
whistleblower complaint form.
Layoff: your position was eliminated, or upwardly /
downwardly allocated to a different class in the course of a
layoff.
Final Grievance Decision: you are appealing a department’s final decision of
your grievance based on a violation of your rights under the federal or state
constitution or the grievance procedures. You must attach a copy of the
original written grievance and the department’s final decision. Check all
that apply:
F
ederal or State Constitutional Rights
Grievance Procedures (Board Rule 8-8)
Administrative Discharge: you were discharged due to
exhaustion of leave.
Decisions of the Director regarding Comparative
Analysis: you are requesting a discretionary review after
receiving the final decision of the State Personnel Director.
Statewide Personnel Director’s Review
Check all boxes that apply
Allocation of your position to a lower pay grade.
External Performance Management Dispute: Original issues involving the
application of your department's performance management program (this does
NOT include dispute of your individual performance rating).
You are objecting to the selection and comparative
analysis process:
Removal of your name from consideration
You are not a Colorado Resident
Rejection of your application
Failure of background check
Failure of assessment
Other hiring process objection
General matter that affects the overall administration of the state personnel
system (except annual compensation survey, granting of in-range salary
movements, discretionary pay differentials, leave sharing, granting and
application of discretionary saved pay during exercise of retention rights, and
job evaluation system and actions).
Other: Fair Labor Standards Act (FLSA), Family Medical Leave Act (FMLA),
American’s With Disabilities Act Amendments Act (ADAAA) regarding
accommodations.
Always attach supporting documentation including the final decision when filing your appeal.
8. SIGNATURE: You (the Complainant) or your legal representative, if applicable, must sign this form. Signature by a legal 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 / _______________________________________________________
or legal representative
9. CERTIFICATE OF DELIVERY TO RESPONDENT: I certify that I have provided a copy of this appeal to Respondent by:
F
irst Class Mail: Hand-Delivery:
O
n this ________ day of ________________, 20____ Signature of Complainant ________________________________________________
You are required to provide a copy of this appeal to the Respondent (#3) on page 1 of this form
AND certify below that you have provided such copy.
