Secon B: Appeal Informaon
CMSD Employee First Name CMSD Employee Last Name
Wellness Incenve
Appeal Request Form
Form Instructions:
Please complete this form to request an appeal regarding the Cleveland Metropolitan School District Wellness Incentive. In order to
request this appeal, please complete Sections A & B of the form below and submit the form via email to Please complete with as much detail as possible to support your appeal request. You may be
contacted for additional information, if necessary. Appeal must be filed within 60 days of when you knew or should have known of the
event for which the relief is requested. This appeal request neither supersedes nor replaces any other grievance process available to you.
Any grievance filing requirements are held in abeyance during this appeal process.
Section A: Employee Information
Employee ID Number Phone Number Email Address
Type of Appeal (Check all that apply) Spouses Name, if spousal appeal requested
Please provide an explanaon for your appeal, including any relevant facts for consideraon by the commiee, and your requested remedy. Please provide any supporng documentaon regarding your
appeal as separate aachment(s) to this appeal request. Please check here if your appeal includes addional separate exhibits
Employee Signature Date
Section C: Appeal Decision—To be completed by CMSD
Appeal Outcome Date
Addional informaon
Bargaining Group Affiliation—Please check appropriate box below.
Building Trades District 1199 Local 279 Local 407 Local 436 Local 777 Local 860 OPBA Non-Bargaining
Employee Spouse
Approved Denied Pended