Fillable Grievance Form - Grievance Form FINAL (Coahoma Community College)

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Grievance Form - Grievance Form FINAL (Coahoma Community College)

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Coahoma Community College
EMPLOYEE / STUDENT GRIEVANCE FORM
This form is to be used if the grievant is not satisfied with the oral decision of his or her immediate supervisor or
dean at the first step of the grievance procedure. This form will be completed at each subsequent step to which the
grievance is advanced. If a grievant is settled orally with the immediate supervisor or dean, this form should not be
used.
Name
Date
Mailing Address
Date of Incident
Position/
Enrollment
Status
Telephone No.
Department/Dept
of Study
Supervisor/Dean
Grievance Statement
!(READ!CA RE FU LL Y)
!Briefly!describe!the!details!of!the!complaint!and!indicate!how!the!college!has!violated!its!policy(s).!!The!evidence!should!include!relevant!
facts!and!documentation!directly!related!to!the !com plaint.!!Indicate !the!tim e!fram e !in!which!th e!violation s!refere nced!in!the!complaint!
occurred.!!
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What!subsequent!actions!did!you!take?!!
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What!actions!did!you!take!to!resolve!the!matter?!!
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What!would!you!like!to!see!happen!as!a!resolution!to!this!matter?
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Grievant’s Signature
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2!
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Decision of Immediate Supervisor/Dean
Date
I am satisfied with the answer to my grievance.
I am not satisfied with the answer to my grievance and wish to
have it advanced to the next step.
Second Step
Reply to the Employee/Student Grievance Next Level
Supervisor’s or Dean’s
Signature
Date
Employee’s / Student’s
Answer
I am satisfied with the answer to my grievance.
I am not satisfied with the answer to my grievance and wish to
have it advanced to the next step.
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3!
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Third Step
Reply to Employee Grievance, Next Level
President’s Signature
Date
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Grievance Form - Grievance Form FINAL (Coahoma Community College)

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Completed 26 July 2020

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