__________________________

Name of agency

Grievance Form

Grievant’s Name ____________________________________

Date filed _________________ Division/Unit/Section __________________________

First Step

Grievance statement : / / Written below, OR / / See Attachment

Relief sought : / / Written below, OR / / See Attachment

Grievant’s signature ______________________________ Date ____________

Cc: Human Resources Office          

First Step Response: Given by _______________________ Job Title ______________

Response is / / Written below OR / / See Attachment

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 Second Step.

Grievant’s signature______________________________ Date ______________

Cc: Human Resources Office          

Grievant’s Name: ____________________________

Second Step

Second Step Response: Given by __________________ Job title ______________

Response is / / Written below OR / / See Attachment

Section head’s 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 Third Step.

Grievant’s signature ______________________________ Date ___________

Cc: Human Resources Office

Third Step

Decision of appointing authority or designee: / / Written below OR

/ / See Attachment

Signature of appointing authority or designee __________________ Date ________

Cc: Human Resources Office    

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