NOTICE: Do NOT use this form if you have received a disciplinary action, have been laid off or have been
administratively separated. Use the Consolidated Appeal/Dispute Form available on the web at:
Print or type.
Keep a copy of the completed grievance form for yourself. Refer to Chapter 8 of the State
Personnel Board Rules and Personnel Director’s Administrative Procedures for information regarding the
grievance process. (Board Rule 8-8)
If you would like to resolve this grievance on an informal basis, with the help of a trained facilitator from
outside your department, then call the State Employees Mediation Program (SEMP) at 303-866-4314 for
STATEMENT OF GRIEVANCE
YES NO. TYPE OF DISCRIMINATION ALLEGED (e.g.,
race, national origin, sex, age, religion):
*NOTE: If the grievance involves an allegation of discrimination, written notice must be sent to the State
Personnel Board, 633 17th Street, Suite 1320, Denver, Colorado 80202-3604, within ten (10) calendar
days of the alleged discriminatory practice.