Fillable TSA-Form1115-1FINALv180202 TSA Form 1115-1

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TSA-Form1115-1FINALv180202 TSA Form 1115-1

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DEPARTMENT OF HOMELAND SECURITY
Transportation Security Administration
GRIEVANCE-MEDIATION REQUEST
INSTRUCTIONS: This Grievance-Mediation Request must be used to file a grievance in accordance with TSA Human Capital
Management (HCM) Policy 771-4, National Resolution Center, and related Handbook. It must be fully completed and submitted
to the National Resolution Center (NRC) at ResolutionCenter@tsa.dhs.gov
or faxed to 703-603-4057. (See HCM 771-4, National
Resolution Center, and Handbook for filing requirements and deadlines).
NOTE: The Filing Party must complete all applicable sections of this Grievance-Mediation Request and provide all necessary
information and supporting documentation. As provided for in HCM 771-4 and Handbook, the Filing Party must provide a detailed
description of the grievance submitted. The NRC will return incomplete forms. Failure to provide the information required below may
result in delay of processing and/or the dismissal of this filing. The Filing Party may include additional pages and attach supporting
documentation as necessary. Questions may be addressed to the NRC at ResolutionCenter@tsa.dhs.gov or 571-227-5097.
If you choose to have a personal representative, TSA Form 1163-1, Personal Representative Designation, must be fully completed.
Do not delay filing this form in a timely manner because you have not selected a personal representative or have not completed TSA
Form 1163-1. You may provide this information at a later date by submitting a completed TSA Form 1163-1.
SECTION I. Affected Employee/Individual
Last Name:
Airport Code/Office:
Phone Number:
Position/Title:
SECTION II. Mediation
TSA Form 1115-1 (2/18) rev. [File: 1100.14.2] Page 1 of 3
In this section, the Filing Party must indicate if they would like to participate in mediation. Please note that informal interest based-
conversations are encouraged at any point in the process. For additional information, please contact the NRC.
Middle Initial:
Email address (that you check regularly):
Has an interest-based conversation taken place between the parties? Yes No
First Name:
a. I would like to participate in mediation to resolve this matter. If mediation is unsuccessful, I would like my allegation(s) to
proceed through the grievance process.
c. I do not want to participate in mediation. I would like my allegation(s) to proceed through the grievance process.
b. I would like to participate in mediation ONLY.
NOTE: By choosing mediation ONLY, you agree that you do not want to pursue the allegation(s) further, even if
management declines to mediate or you are dissatisfied with the results of the mediation.
SECTION III. Allegation(s) Involving Disciplinary Actions and/or Workplace Disputes
This section must be completed if the allegation(s) involves disciplinary actions and/or workplace disputes as set forth in HCM 771-4
and related Handbook.
a. What management action(s) or decision(s) are you grieving? Please explain:
Page 2 of 3 TSA Form 1115-1 (2/18) rev. [File: 1100.14.2]
b. On what date did you become aware of the alleged action(s) or decision(s)?
c. What is the date of the alleged action(s) or decision(s) (if different than date above)?
• NOTE: If you are grieving an alleged management action(s) or decision(s), you must attach a copy as supporting
documentation, including the signature page that indicates the date you were issued the action or decision (e.g., disciplinary
action, letter of leave restriction, AWOL notice).
d. If this allegation(s) does not involve a disciplinary action (i.e., letter of reprimand to a suspension of 14 days or less), do you
allege a violation of TSA policy? If so, which TSA policy (include the specific section(s)), who allegedly violated it, and how?:
SECTION IV. Determination-Related Allegation(s) (Which May Include Alleged CBA Violations)
This section must be completed if there is an alleged violation(s) related to the Administrator's Determination on Transportation
Security Officers and Collective Bargaining (Determination), including an alleged violation(s) of the Collective Bargaining Agreement
(CBA) between TSA and AFGE.
Please check only the sections that apply to your allegation(s) (if applicable):
Section V.C.9.b.i:
Allegation(s) that TSA management or the exclusive representative (AFGE) violated covered employee(s)'
rights as set forth in Section IV.A of the Determination.
Please indicate the subsection(s) of Section IV.A allegedly violated:
Section V.C.9.b.ii:
Allegation(s) that TSA management or the Union (AFGE) did not act in a manner consistent with its
respective rights, roles, and responsibilities in Section IV.C for the Union and Section IV.D for TSA
management.
Please indicate the subsection(s) of Section IV.C or Section IV.D allegedly violated:
Section V.C.9.b.iii:
Allegation(s) that TSA management or the exclusive representative (AFGE) failed or refused to comply with
a binding collective bargaining agreement. Please identify below the relevant Article, Section(s), and
Subsection(s) (if applicable) of the CBA alleged to be violated.
(i) Which Article of the CBA is alleged to be violated?
(ii) Section(s)?
(iii) Relevant Subsection(s) (if applicable)?
(Section IV continues on the next page)
TSA Form 1115-1 (2/18) rev. [File: 1100.14.2] Page 3 of 3
SECTION V. Requested Remedy
a. Please provide a detailed explanation of each of your allegations. For example if you allege that the CBA or Determination
was violated, please explain the specific provision allegedly violated, who allegedly violated it and when, and how it was
allegedly violated. Please also include copies of any relevant documentation.
b. On what date did you become aware of the alleged violation(s)?
c. Please indicate whether your allegation(s) is LOCAL in scope (e.g., your airport only) or NATIONAL in scope (e.g., actions
alleged to occur at multiple airports nationwide or allegations involving a national-level decision). Provide an explanation as
appropriate.
Specify the requested remedy, i.e., the specific relief directly benefitting the affected party(ies) which relates directly to the
allegation(s). It may not include a disciplinary or other action affecting a third party, and it must be consistent with TSA policy.
SECTION VI. Other Forms of Resolution Sought
Have you sought another avenue of external redress, (including but not limited to, filing an Equal Employment Opportunity (EEO)
complaint with the Office of Civil Rights Diversity and Inclusion Division; filing an appeal to the MSPB?
Yes No (check one)
If yes, in which forum:
Note: Please note that allegations of discrimination must be submitted to the Civil Rights Diversity and Inclusion Division. Filing this
Grievance-Mediation Request does NOT extend your time to file an EEO matter.
Additionally, if after filing this Grievance you seek redress in another forum on the same allegation(s), you must promptly notify the
NRC.
PRIVACY ACT STATEMENT: AUTHORITY: 49 U.S.C. 114(n) authorizes the collection of this information. PRINCIPAL
PURPOSE(S): TSA will use this information in the investigation and resolution of your grievance. ROUTINE USE(S): This information
may be shared in accordance with the routine uses identified in the following systems of records notices: DHS-ALL-018 Grievances,
Appeals, and Disciplinary Action, MSPB/GOVT-1 Appeals and Case Records, EEOC/GOVT-1 EEO in the Federal Government
Complaint and Appeals Records, and OSC/GOVT-1 OSC - Complaint Litigation and Political Activity Files. DISCLOSURE: Voluntary.
Failure to provide this information could result in a delay or inability to resolve your grievance.
SECTION VII. Acknowledgement
I affirm the information on this form is true and accurate to the best of my knowledge and belief.
Signature: Date:
NOTE: The Affected Employee/Individual (identified in Section I. of this form) must sign above (not the personal representative).
WARNING: This record may contain Sensitive Security Information that is controlled under 49 CFR parts 15 and 1520. If so, no part
of this record may be disclosed to persons without a "need to know", as defined in 49 CFR parts 15 and 1520, except with the written
permission of the Administrator of the Transportation Security Administration or the Secretary of Homeland Security. Unauthorized
release may result in civil penalty or other action. For U.S. government agencies, 5 U.S.C. 552 and 49 CFR parts 15 and 1520
govern public disclosure.
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TSA-Form1115-1FINALv180202 TSA Form 1115-1

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Completed 3 July 2020

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