Fillable EMPLOYEE GRIEVANCE FORM (Pensacola State College)

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EMPLOYEE GRIEVANCE FORM (Pensacola State College)

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EMPLOYEE
GRIEVANCE FORM
Name ____________________________________________ Date _______________
Address ________________________________________________________________
(City) (State) (Zip Code)
Telephone No. _____________________ E-mail Address: ______________________
Employee ___________ Student Employee _____________ Other ____________
Department ____________________________________________________________
If presently an employee, who is your present supervisor?
_______________________________________________________________________
Who was your former supervisor? _________________________________________
(If complaint involves a former supervisor)
A. Describe the facts associated with your grievance. Be as specific as possible
concerning dates, times, and witnesses if applicable. (Attach numbered
additional sheets if necessary.)
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
B. With whom have you discussed this problem?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Pensacola State College
Employee Grievance Form (continued)
Page 2
C. If the grievance applies to a specific college policy, procedure or rule that has
allegedly been violated, state it below.
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
D. If the grievance relates to discrimination or harassment, indicate below the
basis of the alleged discriminatory practice.
Race/Ethnicity ____ Gender Identity ____ Genetic Information _____
Age _____ Disability _____ Marital Status ______ Color ______
National Origin ______ Religion ______ Title IX _____ Pregnancy _____
Sexual Orientation ____ Other _________________________
E. What action would you suggest to remedy your grievance?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
__________________________________________ __________________
Signature Date
Please return this form to the Director of Institutional Diversity/Title IX, Pensacola State College, 1000 College
Boulevard, Pensacola, Florida 32504.
Pensacola State College does not discriminate against any person on the basis of race, ethnicity, national origin, color, gender/sex, age, religion,
marital status, pregnancy, disability, sexual orientation, gender identity, or genetic information in its educational programs, activities or
employment. For inquiries regarding Title IX and the college’s nondiscrimination policies, contact the Director of Institutional Diversity/Title IX
at (850) 484-1759, Pensacola State College, 1000 College Blvd., Pensacola, Florida 32504.
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EMPLOYEE GRIEVANCE FORM (Pensacola State College)

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Completed 25 August 2020

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