GRIEVANCE NON-COMPLIANCE NOTIFICATION FORM
Non-Compliance Addressed To:
Name of Person Sending Non-Compliance:
Instructions: Use this form as notification of non-compliance at any step of the grievance process. This serves to notify
the addressee that you have not complied with the City's grievance procedure due to the following ( State which step
the non-compliance occurred):
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Please Take Notice: That compliance must occur within five (5) working days of
your receipt of this notice or a decision may be made in my favor
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Signature of Person Sending Non-Compliance
(MM/DD/YR)
(HR Form # 23)
DISTRIBUTION
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HR Copy
Grievant's Copy
Appointing Authority's Copy
Immediate Supervisor's Copy
Requested:
Complaint #Step #
(MM/DD/YR.)
(Last)(MI)(First)
(Last)(MI)(First)
HR USE ONLY
Date Rec'd.:
Log Date:
By:
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