Stockbridge-Munsee Community (SMC)
Initial Employee Grievance Review Form
Initiating Step 1 in the Grievance Process: I understand by completing the initial employee grievance review form this does not
constitute it as a grievance. The form will be reviewed by the Employee Relations Representative to define what is grievable in
accordance to the Employment Manual, as well as Chapter 53 (SMC Employee Rights Ordinance).
Send to your direct supervisor and copy the Employee Relations Representative within five (5) working days of the incident giving
rise to the complaint. The first working day begins the day after the form is submitted (Monday-Friday, Non-Holiday).
Employee is submitting grievance form for the following reasons:
___ Forms of harassment that interfere with job performance or create a hostile or offensive working environment. (If you marked this box,
STOP. Please fill out Anti-Harassment Form to initiate Section 4 instead.)
___ The Employment Manual has been violated. EMPLOYEE PROVIDES: 1) What has been violated by page and section, and 2) Supporting
documentation of alleged violation.
___ Direct violation of Terms & Conditions of Employment. EMPLOYEE DEFINES: 1) What has been violated (pay, hours, PTO, scheduling,
benefits, evaluations), and 2) Supporting documentation of alleged violation.
Describe in detail the reasons for submission: (Include date(s), time(s), place(s), people involved, work rule(s) involved, etc.)
Employee requests the following solution to resolve the complaint. If the request is fulfilled, the matter is closed:
Employee Signature: _________________________________________________ Date:
_____________
Confidentiality - As an employee of SMC who has initiated the Grievance Process I agree to adhere to strict
confidentiality. I agree not to repeat any of the information I may hear as part of the Grievance Process. I
understand that if I break confidentiality I will be subject to disciplinary action.
Retaliation - I also understand that the SMC will not tolerate any retaliation against any employee who files a
complaint/grievance or provides information related to the complaint/grievance Remember to keep your focus on
your work and keep your interaction neutral, civil and job related. SMC does expect you to be cordial and polite.
It’s not OK to refuse to speak to the person or spread rumors or false accusations. Violation of these simple rules
could result in disciplinary action.
Date Received: ________________
Response Due: ________________
Representative: _____________
