GRIEVABILITY NOTIFICATION FORM
Requested:
Complaint #Step #
(MM/DD/YR.)
Grievant's Name:
(Last)(MI)(First)
Requested By:
(Last)(MI)(First)
Instructions: Use this form to request a determination of grievability. This can be done at any time after a complaint has been
filed but prior to a hearing before the PersonnelBoard. This section will be completed by the Department of Human
Resources for all matters which reach the third step prior to the complaint being heard by the Chief Administrative
Officer's Designee.
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Reason for Request:
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DateSignaturePrint Name
Decision is : Applicable Rule(s)
Grievance is forwarded to Step:
Grievable:
Reviewed By:
Non-grievable:
Date of Review:
Relief must be amended:
Split Determination:
(HR) Form # 22)
DISTRIBUTION
White
Green
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Canary
To Next Step
HR Copy
Grievant's Copy
Appointing Authority's Copy
Immediate Supervisor's Copy
HR USE ONLY
HR USE ONLY
Date Rec'd.:
Log Date:
By:
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