Employee Grievance Form
Employees should use the grievance procedure outlined in the Employee Conflict Resolution and Grievance policy to
address claims related to violations of College policies and procedures or unlawful harassment, including sexual
misconduct and discrimination. Employees should also use this grievance procedure if they feel that the written conditions
of employment or published regulations, policies, or procedures were inequitably applied in an impending disciplinary
action, up to and including termination. Please review the Employee Conflict Resolution and Grievance policy prior to
completing this form.
Employees must provide a specific statement of their grievance and indicate what solution or remedy they expect. Any
documentation that relates to the substance of the grievance or facilitates its understanding should be attached to this
form.
Employee Information
Full Name: __________________________________________________________________________
Employee ID #: _____________________
Phone Extension: ___________________
Email Address: _________________________________________
Basis of Grievance
☐ Violation of College Policies and Procedures
☐ Unlawful Harassment
☐ Inequitable application of Written Conditions of Employment or Published Regulations, Policies, or Procedures
Please further explain the basis of your grievance, providing specific details, such as specific policies and procedures, to
substantiate your claim.
Please explain the resolution or remedy you are seeking.
Supporting Documentation
Please describe the documentation here, and attach it to this form prior to submission.
E
mployee Signature:
_______________________________ Date Submitted: __________________
For H
uman Resources and Office of Institutional Equity and Inclusion Use Only
Executive Director of Human Resources Signature: ______________________________________
Date Received: __________________
Special Assistant, Institutional Equity and Inclusion/Affirmative Action Officer
Signature:______________________________________
Date Received: __________________
Revised 2/12/2020
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