1
GRIEVANCE FORM
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:
http://www.colorad
o
.gov/
spb.
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
this assistance.
GRIEVANT’S NAME:
GRIEVANT’S ADDRESS:
REPRESENTATIVE:
REPRESENTATIVE’S ADDRESS:
EMPLOYING DEPARTMENT:
STATEMENT OF GRIEVANCE
RELIEF REQUESTED
DISCRIMINATION
ALLEGED*:
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.
2
REPORTING CHAIN:
(Complete where applicable)
First/Second Line Supervisor (name):
Date of the informal discussion with the First/Second Line Supervisor:
Date the Step 1 informal discussion with the First/Second Line Supervisor was
concluded:
Appointing Authority (name):
Date Written Grievance was submitted to the Appointing Authority:
Date of the meeting with the Appointing Authority:
Date Grievant
received the Step 2 Written Response from the Appointing Authority:
Date Petition for Hear
ing was either filed with, or postmarked to, the State Personnel Board:
Grievant's Signature:
Date:
Revised 11/2009
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