Microsoft Word - 2534GrievanceForms.doc

From: Grievance Procedures for Teaching Faculty, Librarians & Academic Counselors with Rank, PR

2534.1B, dated December 17, 1996.

Forms

Problem Solving at the Immediate Supervisor Level (Form 2534/001)

Respondent's Problem Solving Response Form (Form 2534/002)

Problem Solving at the Intermediate Supervisor Level (Form 2534/003)

Problem Solving at the Vice President Level (Form 2534/004)

Request for Grievance Hearing (Form 2534/005)

Notice of Grievance Committee Selection (Form 2534/006)

Respondent's Response to Hearing Request (Form 2534/007)

Notice of Grievance Committee's First Meeting (Form 2534/008)

Review of Request for Grievance Hearing (Form 2534/009)

Notice to Appear at Grievance Hearing (Form 2534/010)

List of Witnesses/Parties Called to Be Present At Grievance Hearing (Form 2534/011)

Grievance Committee's Report of Findings and Recommendations (Form 2534/012)

Grievance Outcome Appeal to the President (Form 2534/013)

DELGADO COMMUNITY COLLEGE

Step 1: Informal Problem Solving at the Immediate Supervisor Level

Meeting Summary Form

Purpose of this form: If an employee has met with his/her immediate supervisor regarding an alleged violation of

College policy and procedure or a problem affecting his/her working conditions, and the employee is not satisfied with

the result of that meeting, the employee requests that his/her Intermediate Supervisor conduct a meeting with the

employee and respondent(s) to discuss the problem. This form is completed by the employee and submitted to the

Intermediate Supervisor, with copies to the respondent(s), to request the Step 2 meeting. Additional pages and/or

documentation may be attached, if needed.

Date of Step 1 Meeting with Immediate Supervisor: :_________________________

Name of Employee Requesting Meeting with Intermediate Supervisor: _________________________________

Dept./Division:___________________________________

Name of Employee's Immediate Supervisor:______________________________________________

Name of Person(s) the Employee has Identified as Respondent(s):

_______________________________________________________________________________________________

Employee Identifies the Problem:

_________________________________________________________________________________________________

__________________________________________________________________________________________

Employee Defines College Policy or Procedures Allegedly Violated or Applied in an Inequitable or Discriminatory

Fashion or WorkRelated Problem:

________________________________________________________________________________________________

_________________________________________________________________________________________________

____________________________________________________________________________________________

________________________________________________________________________________________________

Employee Defines the Facts Which Demonstrate the Above:

________________________________________________________________________________________________

_________________________________________________________________________________________________

_____________________________________________ _____________________________

Signature of Employee Requesting Step 2 Meeting Date

Form 2534/001

Attachment B

DELGADO COMMUNITY COLLEGE

Respondent's Problem Solving Response Form

Date: ________________________________

To: ________________________________

Address: ________________________________

________________________________

From: ________________________________ ________________________________

Intermediate Supervisor College Title

________________________________

Office Phone Number

_______________________________ (name of employee) has requested a meeting to discuss the attached

alleged problem (see attached copy of Form 2534/001) and has identified you as a respondent.

To provide me with your response to these allegations, complete the following and bring it with you to the

meeting on _______________________ (date) at which time we will discuss the problem. Additional pages

and/or documentation may be attached, if needed.

* * * * * * * * * * * * * * * * * To Be Completed by Respondent * * * * * * * * * * * * * * * *

Your Response to the Employee's Identification of the Problem:

____________________________________________________________________________________

Your Response to the Employee's Definition of College Policy and Procedures Which Were Allegedly

Violated or Applied in an Inequitable or Discriminatory Fashion:

____________________________________________________________________________________

Your Response to the Employee's Representation of the Facts:

____________________________________________________________________________________

_____________________________ _____________________

Respondent's Signature Date

(Copy of Form 2534/001 must be attached.)

Form 2534/002

DELGADO COMMUNITY COLLEGE

Step 2: Formal Problem Solving at the Intermediate Supervisor Level

Meeting Summary Form

Purpose of this form:

If an employee requests a meeting with his/her Intermediate Supervisor to discuss an alleged

violation of College policy and procedure or a problem affecting his/her working conditions which was previously

discussed with his/her Immediate Supervisor (Step 1), the Intermediate Supervisor calls a meeting with the employee and

the respondent(s). To document the discussion, this form is completed and signed by all parties involved at the end of

the Step 2 meeting. Additional pages and/or documentation may be attached, if needed.

Date of Step 2 Meeting with Intermediate Supervisor:_________________________

Name of Employee Requesting Step 2 Meeting : _________________________________

Dept./Division:_____________________________________________________________

Name of Intermediate Supervisor:______________________________________________

Name of Immediate Supervisor: _______________________________________________

Name of

Respondent(s):_________________________________________________________________________________

Steps Recommended by the Intermediate Supervisor to Remedy the Problem:

_________________________________________________________________________________________________

I recommend the remedy listed above.

______________________________________

Signature of Intermediate Supervisor

_____ I accept the recommended remedy

. (Or) ______

I disagree for the following reason(s):

_________________________________________________________________________________________________

____________________________________

Signature of Employee Requesting Meeting

_____

I accept the recommended rem

edy. (Or) ______

I disagree for the following reason(s):

_________________________________________________________________________________________________

____________________________________________________________________________________________

_______________________________

Signature of Respondent

(Copy of completed forms 2534/001 and 2534/002 must be attached to this form

.) Form 2534/003

DELGADO COMMUNITY COLLEGE

Step 3: Formal Problem Solving at the Vice President Level

Meeting Summary Form

Purpose of this form

If an employee requests that the appropriate Vice President review an alleged violation of College

policy and procedure or a problem affecting his/her working conditions which was previously discussed with his/her

Immediate Supervisor (Step 1) and his/her Intermediate Supervisor (Step 2), the Vice President meets with the

Intermediate Supervisor and discusses a solution. As a result of that meeting (Step 3), the Vice President uses this form

to make recommendations and attaches copies of forms documenting Step 1 and 2.

Date of Step 3 Meeting of Vice President and Intermediate Supervisor:_________________________

Name of Employee Requesting Step 3 Meeting: __________________________________

Dept./Division:_____________________________________________________________

Name of Intermediate Supervisor:______________________________________________

Name of

Respondent(s):_________________________________________________________________________________

Steps Recommended by the Vice President to Remedy the Problem:

_________________________________________________________________________________________________

I recommend the remedy listed above.

______________________________________

Signature of Vice President

_____

I accept the recommended remedy

. (Or) ______

I disagree for the following reason(s):

_________________________________________________________________________________________________

_______________________________

Signature of Employee Requesting Meeting

_____

I accept the recommended remedy

. (Or) ______

I disagree for the following reason(s):

_________________________________________________________________________________________________

______________________________

Signature of Respondent

(Copies of completed forms 2534/001, 2534/002, and 2534/003 must be attached to this form.)

Form 2534/004

DELGADO COMMUNITY COLLEGE

Request for Grievance Hearing

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

PART A:

(Part A to be completed by the Grievant and submitted to the Grievance Officer, within three (3) working

days after Step 2 or Step 3. The Grievance Officer will in turn call a meeting of the grievant and respondent(s) to select

a Grievance Committee for this specific grievance.)

Date: ________________________

Name of Grievant Requesting Hearing: _______________________________________

Department/Division: _______________________________________________________

Name of Respondent(s):_____________________________

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

PART B:

(Part B to be completed by the Grievant, and submitted to the Grievance Officer, prior to or at the meeting at

which the Grievance Committee is selected.)

I request a grievance hearing on the following issues and I recommend the following remedies.

Specific, Grievable Issue(s):

(If more than one, number each issue.)

_________________________________________________________________________________________________

Define College Policy or Procedures Allegedly Violated or Applied in an Inequitable or Discriminatory Fashion or

a Problem Affecting Working Conditions:

(Identify the number of the issue for each policy/procedure, as applicable.)

_________________________________________________________________________________________________

Define the Facts Which Demonstrate the Above:

_________________________________________________________________________________________________

Specific, Recommended Step(s) to Remedy the Problem

: (

Number each if more than one.)

_________________________________________________________________________________________________

___________________________________

Signature of Employee Requesting Hearing

Form 2534/005

DELGADO COMMUNITY COLLEGE

Notice of Grievance Committee Selection

Date: _______________________________

To: _______________________________

Address: _______________________________

_______________________________

From: ________________________________

________________________________

Grievance Officer College Title

________________________________

Office Phone Number

You are hereby notified that _______________________________ (name of grievant) has officially

requested a grievance hearing in regard to the attached alleged grievance and has identified

____________________________________________________________________________________

the respondent(s).

The first step in response to this request will be to select a Grievance Committee from the College's

Grievance Pool.

Grievance Committees are selected by lot, by the Grievance Officer, with the grievant and

respondent(s) present. The selection of the Grievance Committee will take place:

Date: ____________________________________

Time: ____________________________________

Place: ___________________________________

To select a Grievance Committee, it is required that the grievant and respondent(s) are present. If

you request an alternative method of selection, it must be agreed upon by the Grievance Officer,

grievant, and respondent(s).

If you have any questions, you may contact me at the phone number listed above.

__________________________________

Grievance Officer's Signature

(Copy of completed form 2534/005 must be attached.)

Form 2534/006

DELGADO COMMUNITY COLLEGE

Respondent's Response to Grievance Hearing Request

Date: ________________________________

To: ________________________________

Address: ________________________________

________________________________

From: ________________________________ ________________________________

Grievance Officer College Title

________________________________

Office Phone Number

_______________________________ (name of grievant) has officially requested a grievance hearing in

regard to the alleged grievance (as defined on attached Form 2534/005) and has identified you as a

respondent.

To provide the Grievance Review Committee with your response to these allegations, complete the following

and return it to my office by _______________________ (within five working days of the date on this form.)

* * * * * * * * * * * * * * PART A: To Be Completed by Respondent * * * * * * * * * * * * * *

Your Response to the Employee's Grievable Issue(s) and the College Policy and Procedures Which Were

Allegedly Violated or Applied in an Inequitable or Discriminatory Fashion or WorkRelated Problem:

____________________________________________________________________________________

Your Response to the Employee's Representation of the Facts and Suggested Remedy:

____________________________________________________________________________________

_____________________________________ ____________________________________

Respondent's Signature Date

(

Continued on Back)

(Copy of completed form 2534/005 must be attached.)

Form 2534/007 (

front)

* * * * * * * * * PART B: To Be Completed by Grievant, If Desired (Optional) * * * * * * * *

Your Reaction to the Respondent's Response in Part A:

____________________________________________________________________________________

_____________________________________ ____________________________________

Grievant's Signature date

Form 2534/007

(back)

DELGADO COMMUNITY COLLEGE

Notice of Grievance Committee's First Meeting

Date:_______________________________

To: ________________________________

Address: ________________________________

________________________________

From: ________________________________ ________________________________

Grievance Officer College Title

________________________________

Office Phone Number

You are hereby notified of the first meeting of the Grievance Committee relative to a grievance

alleged by___________________________ (name of grievant) who has identified _____________

________________________________________________________________________________

_______________________________________________________________as the respondent(s).

You have been identified as a/the (check one):

_____grievant _______ respondent _______ committee member

All committee members are required to be present at this meeting. Neither the respondent nor the

grievant will be present at the meeting. If they are requested to appear, they will be notified.

For your information, the Committee's first meeting is scheduled for the following:

Date: ____________________________________

Time: ____________________________________

Place: ___________________________________

Form 2534/008

DELGADO COMMUNITY COLLEGE

Review of Request for Grievance Hearing

Date: _________________________________

Grievant's Name: _______________________________ Title: ___________________________

Department/Division: ____________________________

Respondent's Name: _____________________________ Title: ___________________________

The Grievance Committee has met to review the request by the above grievant for a hearing on the alleged

grievance. The Committee has determined the following:

(Attach additional pages if necessary.)

_______ The Committee agrees that a grievance exists (as defined in Section 4 of Policy and Procedures

Memorandum PR2534.1B), and makes the following recommendation(s) to solve the grievance:

______________________________________________________________________________

_______ The Committee approves the request for a hearing. (The Committee determines that a specific

provision(s) of official College policy and procedures may have been violated or applied in an

inequitable fashion or that a workrelated problem may exist.) A hearing is necessary to discuss the

issues listed below. (No other issues will be discussed at the hearing.)

______________________________________________________________________________

Please note the following:

1. All parties involved

will receive notification of the date, time and place of the hearing.

2. The grievant and respondent(s) are required to be present at the hearing.

3. You have a right to have witnesses/parties called to be present at the hearing.

Witnesses/parties called to be present must be limited to members of the College community

(faculty, staff and/or students). To have witnesses/parties called, you must submit Form

2534/011 to the Committee Chair within three (3) working days of the date on this form.

_______ The Committee denies the request for a hearing. (The Committee determines that the following

provision(s) of official College policy and procedure clearly was not violated or applied in an

inequitable or discriminatory fashion or a workrelated problem clearly does not exist, as explained

below.)

________________________________________________________________________

Signature of Committee Chair: __________________________ Date: _____________________

Signature of Committee Members: __________________________ __________________________

__________________________ __________________________

(Copies of completed forms 2534/005, and 2534/007 must be attached.)

Form 2534/009

(front)

* * * * * * * * * * * * * * * * * * * To Be Completed By Grievant* * * * * * * * * * * * * * * *

________ I accept the Committee's recommendation(s).

________ I do not accept the Committee's recommendation(s) and I understand that this rejection of the

recommendation(s) will result in a full hearing.

________ I am appealing the denial of a hearing to the President. (Attach Grievance Outcome Appeal

to the President Form, Form 2534/013.)

___________________________________ ____________________________

Signature of Grievant Date

Form 2534/009

(back)

DELGADO COMMUNITY COLLEGE

Notice to Appear at Grievance Hearing

Date:_______________________________

To: ________________________________

Address: ________________________________

________________________________

From: ________________________________ ________________________________

Grievance Officer College Title

________________________________

Office Phone Number

You are hereby notified to appear at a hearing on a grievance alleged by________________________

___________________________ (name of grievant) who has identified _______________________

____________________________________________________________________________________

_______________________________as the respondent(s).

You have been identified as a/the _______________________________(grievant, respondent, witness, etc.)

in this grievance process and your presence is required at the hearing.

The hearing is scheduled for the following:

Date: ____________________________________

Time: ____________________________________

Place: ___________________________________

Information for the grievant and respondent(s):

1. You may request a postponement of the hearing, in writing, within three (3) working days of this notification if

you have a valid reason (for example, scheduled vacation, away on College business, or a prior commitment

you are unable to rearrange.) The postponement may not be longer than ten (10) working days from the date of the

originally scheduled hearing.

2. It is recommended that you consult the College's official grievance policy in regard to how grievance hearings

are conducted.

3. You have a right to have witnesses/parties called to be present at the hearing. Witnesses/parties called to be

present at the hearing must be limited to members of the College community (faculty, staff and/or students). To

request witnesses/parties to be called to be present at the hearing, you should submit Form 2534/011 to the

Committee Chair within three (3) working days of the date on this notice.

If you have any questions, you may contact me at the phone number listed above.

__________________________________

Grievance Officer's Signature

Form 2534/010

DELGADO COMMUNITY COLLEGE

List of Witnesses/Parties Called to Be Present At Grievance Hearing

Date: _______________________

To: _______________________ Grievance Officer

From: ___________________________

(Check one:

_____Grievant ______ Respondent)

Re: Grievance Hearing regarding: Grievant: ______________________________

Respondent(s): ______________________________

I would like to request that the following person(s) be called to be present at the hearing scheduled to discuss the

grievance between the parties listed above.

Person Requested

Affiliation with the College Role of this Person at the Hearing

___________________ ____________________ ____________________________________

_________________________________

Signature

Received By:

________________________________ ___________________________________

Signature of Committee Chair Date

Form 2534/011

DELGADO COMMUNITY COLLEGE

Grievance Committee's Report of Findings and Recommendations

Committee Chair should send completed original of this form to the President within ten (10) working days after hearing,

with a copy of completed form 2534/007 attached.

Date:______________________________

To: ______________________________ (President)

From: Grievance Committee

______________________________ (Chair) ______________________________ (Member)

______________________________ (Member ______________________________ (Member)

______________________________ (Member)

Re: Grievance Hearing on ______________________________ (date of hearing)

Grievant: ___________________________/ Respondent(s): _______________________________________

We issue the following findings and recommendations in regard to the grievance hearing mentioned above. (Use

additional pages if necessary; additional pages must be attached.)

_______ A finding that the complaint is not justified (that no provision of official College policy and procedure

has been violated or applied in an inequitable or discriminatory fashion or that no significant work

related problem exists) and recommend that all charges be dismissed. The following is a

justification supporting this decision:

_____________________________________________________________________________________

_______ Concurrence with the grievant (that a provision of official College policy and procedures has been

violated or applied in an inequitable or discriminatory fashion or that a significant workrelated

problem exits). The following includes (1) a justification supporting this decision which includes the

specific provisions violated or applied in an inequitable or discriminatory fashion; and (2) specific

recommendations for solving the grievance.

_____________________________________________________________________________________

_____________________________ _______________________________ ____________________________

Committee Chair's Signature Member's Signature Member's Signature

____________________________ _______________________________

Member's Signature Member's Signature

(Note: President's Response on Back Page)

Form 2534/012

(front)

 For Use by President Only 

President should send original of completed final report and all attachments to the Grievance Officer with copies of the

form to the Committee Chair, the Grievant and the Respondent(s) within five (5) working days after receiving

Committee's findings and recommendations.

Date: _______________________

Re: Grievance Hearing on ______________________________ (date of hearing)

Grievant: ___________________________ Respondent(s): ____________________________________

________ I accept the Committee's findings and will take the Committee's recommended step(s) to remedy the

situation.

________ I accept the Committee's findings and will modify the Committee's recommended step(s) to remedy the

situation. The following is the modified recommendations: (Use additional pages if necessary;

additional pages must be attached.)

_____________________________________________________________________________________

________ I deny the Committee's findings, for the following explicit reasons, and will take the following

recommended step(s) to remedy the situation. (Use additional pages if necessary; additional pages

must be attached.)

_____________________________________________________________________________________

______________________________________________ __________________________________________

Signature of President Date

Form 2534/012

(back)

DELGADO COMMUNITY COLLEGE

Grievance Outcome Appeal to the President

A grievance appeal should be made within ten (10) working days after receiving the Grievance Committee's Report. A

copy of the appropriate report that is being appealedthe Review of Request for Grievance Hearing (Form 2534/009) or

the Grievance Committee's Report of Findings and Recommendations (Form 2534/012)must be attached.

Date: ________________________

Name of Grievant Requesting Appeal: _______________________________________

Department/Division: _______________________________________________________

Name of Respondent(s): ______________________________

I request an appeal of the grievance report, as attached. The following states the specific reasons as to why the decision

and/or recommendations are not acceptable to me.

_________________________________________________________________________________________________

__________________________________________

Signature of Grievant Requesting Appeal

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _For Use By the President Only _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_________ I uphold the grievance report and will not accept the appeal of the decision for the following reasons.

_____________________________________________________________________________________

_________ I accept the appeal, for the following specific reasons, and I recommend the following course of action

to remedy the situation.

_____________________________________________________________________________________

__________________________________________ ___________________________________

Signature of President date

President should send original of appeal form and all attachments to the Grievance Officer with copies sent to the Vice President, the

Committee Chair, the Grievant and the Respondent(s) within five (5) working days after receiving the appeal form.

Form 2534/013