SF16

GRIEVANCE FORM

 

This form is to be used if the grievant is not satisfied with the decision of his/he

immediate supervisor at the First Step of the grievance procedure. The form will

be completed at each subsequent Step at which the appeal is made. If a

grievance is settled orally with the immediate supervisor, written record is not

mandatory. However, a memorandum record of the grievance for agency use is

advisable in such cases.

 

AGENCY ______________________________

 

DATE __________________

NAME ___________________________________________________________

 

JOB CLASSIFICATION ______________________________________________

 

 

GRIEVANCE STATEMENT

 

 

 

 

 

 

RELIEF SOUGHT

 

 

 

 

 

 

______________________________________

 

 

 

DECISION OF IMMEDIATE SUPERVISOR

 

 

 

 

 

 

i _________________________ e _________________

 

 

 

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SECOND STEP

 

SECTION, DIVISION OR UNIT HEAD

 

 

Reply to Employee Grievance: _____________________________

 

______________________________________________________

 

______________________________________________________

 

Signature ___________________________ Date ______________

 

 

 

Employee Answer

 

I am satisfied with the answer to my grievance

 

I am not satisfied with the answer to my grievance and wish to have it

referred to the next step.

 

THIRD STEP

 

AY’

 

 

Recommendation(s) of Hearing Officer or Grievance Committee:

 

________________________________________________________________

_______________________________________________________________

________________________________________________________________

________________________________________________________________

 

Signature _________________________________ Date __________________

 

 

Decision of Appointing Authority:

 

________________________________________________________________

________________________________________________________________

________________________________________________________________

 

Signature _________________________________ Date __________________

 

 

 

 

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