Formal Grievance Form
This form is to be used to file a formal grievance. All four sections must be completed and will serve as the source
document for the grievance process (attach additional pages if more room is necessary). Please answer all questions
fully. All supporting documentation must be attached to this grievance form at the time the grievance is filed. Additional
information may be requested as necessary.
Name: ____________________________________________________________________________________
Status: Student Employee Other - ____________________________________
Basis of Complaint: Harassment Discrimination Unfair Action / Violation of Rights
Grievance is filed under: Harassment and Non-Discrimination Policy Staff/Admin General Grievance Policy
Preferred Method to Contact You: _______________________________________________________________
1. What was the date of occurrence and what specific behavior, condition, or violation of policy or procedure
occurred which you consider discriminatory, harassing or unfair / violated your rights?
2. How have you been adversely affected by this situation?
3. What specific action have you taken to follow the guidelines for informal resolution as outlined in the
Grievance Procedures for Discrimination and Harassment or the Staff and Administrative Grievance Policy?
What has been the outcome of these efforts?
4. What specific remedy do you request?
Signature: __________________________________________________ Date Filed with HR: ____________
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