Fillable Grievance Form (City)

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Grievance Form (City)

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The Grievance Form (City) form is 3 pages long and contains:

  • 4 signatures
  • 10 check-boxes
  • 46 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City

BROWSE CITY (AR) FORMS

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GRIEVANCE FORM
SUBMITTED BY:
______________________________________ ______________________________
Name Date
______________________________________ ______________________________
Job Title Department/Division
______________________________________ ______________________________
Union Steward Date
FORWARDED TO IMMEDIATE SUPERVISOR ON _________________________
Date
Acknowledgement of receipt of the grievance:
______________________________________ ______________________________
Immediate Supervisor Signature Department/Division/Date
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signature
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STEP ONE:
Grievance Statement: (To be Completed by Grievant or Union Steward)
State your grievance in the space below. Indicate the Article of the Memorandum and/or
the Section of the Administrative Personnel Policy and Procedure Manual which you feel
were violated. Use additional pages if needed.
Article: _____________________ Section: __________________________
I (we) believe the stated article/policy was misapplied on: _______________________
Date
because: ________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
I believe a just and fair solution to the grievance is: _____________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
The following solution was offered (to be completed by immediate supervisor): ___
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
No solution was offered.
__________________________________________ _______________________
Immediate Supervisor Signature Date
I accept the proposed solution. I do not accept the proposed solution.
No solution was offered.
__________________________________________ _______________________
Grievant Date
__________________________________________ _______________________
Union Steward Date
If a solution was not reached, the grievant may forward the grievance to the next
step.
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signature
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STEP TWO:
Department Director
Date grievance was received: ___________________:
The following solution was offered (to be completed by the Department Director):
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
No solution was offered.
__________________________________________ _______________________
Department Director Signature Date
I accept the proposed solution. I do not accept the proposed solution.
No solution was offered.
__________________________________________ _______________________
Grievant Date
__________________________________________ _______________________
Union Steward Date
If a solution was not reached, the grievant may forward the grievance to the next step.
STEP THREE:
Director of Human Resources
Date grievance was received: ______________________________________________
A hearing was scheduled:
Yes No If yes, date: _____________________
Attached is the Written Determination Yes
of the City Manager. No – If no explain below
Dated: ___________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Signature of City Manager Representative: ____________________________________
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Grievance Form (City)

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Completed 18 July 2020

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