DELGADO COMMUNITY COLLEGE
Request for Grievance Hearing
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PART A: Part A to be completed by the Grievant and submitted to the Grievance Officer, within five (5) working days of completing Phase I: Problem Solving. 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): _____________________________________________________
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 That Demonstrate the Above:
Specific, Recommended Step(s) to Remedy the Problem: (Number each if more than one.)
___________________________________
Signature of Employee Requesting Hearing
Received:
Grievance Officer’s Signature __________________________________ Date_________________
Printed Name of Grievance Officer: _______________________________ College Title: _______________________
Form 2534/005 (5/17) (front)
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PART B: (Part B to be completed by Respondent and submitted to the Grievance Officer, prior to or at the meeting at which the Grievance Committee is selected.)
Name of Respondent(s): _______________________________ Dept./Division: ______________________________
The grievant named on Part A of this form has officially requested a grievance hearing in regard to the alleged grievance as defined by the grievance on this form and has identified you as a respondent. To provide the Grievance Review Committee with your response to these allegations, complete the following:
Your Response to the Employee's Grievable Issue(s) and the College Policy and Procedures That Were Allegedly Violated or Applied in an Inequitable or Discriminatory Fashion or Work-Related Problem:
Your Response to the Employee's Representation of the Facts and Suggested Remedy:
_____________________________________ ____________________________________
Respondent's Signature Date
Received: Grievance Officer’s Signature _______________________________ Date_______________
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PART C: (To Be Completed by Grievant, if desired (optional) and provided to Grievance Officer for delivery to Grievance Committee prior to their first meeting.)
Your Reaction to the Respondent's Response in Part B:
_____________________________________ ____________________________________
Grievant's Signature Date
Received: Grievance Officer’s Signature _______________________________ Date_______________
Form 2534/005 (back) (5/17)
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