2. Notification of Problem Form



Notification of Problem Form

Purpose of this form: This form is used when an employee wants a meeting to address an alleged violation of College policy and procedure or a problem affecting his/her working conditions. The employee wishing to address a problem determines a “Mediator” through the chain of command to serve as a neutral party with whom the Informal Problem Solving Phase is initiated and to impartially move the process forward. The Mediator must be either the (1) the immediate supervisor, (2) the intermediate supervisor, or (3) the Vice Chancellor for Academic Affairs, but cannot be the Respondent.
Name of Employee Requesting Meeting: _________________________________

Dept. /Division: ___________________________________

Name of Person the Employee Has Identified as Mediator: ____________________________________________

The Mediator is the (choose one):
____ Immediate Supervisor   ____ Intermediate Supervisor  ____ Vice Chancellor for Academic Affairs

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 Work-Related Problem:

Employee Defines the Facts That Demonstrate the Above:

_____________________________________________    _____________________________
Signature of Employee Requesting Meeting        Date  

                     Form 2534/001 (5/17)

Employee Submits Form to Designated Mediator; Upon Receipt Mediator Sends Copy to College’s Grievance Officer

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