Staff Grievance Form

Sunday, December 22, 2024

Name:

E-mail:

Mailing Address:

City, State, Zip Code:

Phone Number(s):

Department:

Job Title:

Person(s) to who(m) the Grievance is addressed:

Immediate Supervisor:

Dean/Director/Department Head’s Name:

This statement must be submitted to the Director of Human Resources within 5 working days of the occurrence which gave rise to the grievance or (2) when the facts giving rise to the grievance became known or should have been known to the employee.

At the filing of the written grievance, the employee (Faculty or Staff) has the option to request the grievance (1) to be investigated by the Director of Human Resources or (2) request a hearing by the appropriate grievance committee.

Select the applicable choice:

Grievance to be investigated by the Director of Human Resources

Grievance to be investigated by the appropriate grievance committee

Please select which provision of the Grievance process your concerns fall under:

an alleged misinterpretation, misapplication, or violation of a specific provision of university policy that materially affects the Grievant’s terms and conditions of employment; and/or,

bullying: includes, but not limited to, repeated and ongoing acts of intimidation, humiliation, or ridicule either written, verbal, electronic, or physical, against the Grievant that materially interferes with the work environment; and/or

terminations which are deemed to be “terminations-for-cause” as defined in Section 14.4 b of the Employee Handbook.

Description of Grievance(s) in detail:

Identify, specifically, what action you would have the University take to resolve your grievance(s):

(Attach additional pages if necessary)

Add another

In filing this grievance I agree to accept the conditions as set forth in the UA-PTC Employee Grievance Procedure. Should I choose to allow the appropriate grievance committee to hear my grievance, I grant the committee access to all information and evidence relevant to the grievance.

Grievant’s Signature:

I understand that typing my full name in this box constitutes a legal signature confirming that I acknowledge and agree to the conditions above.

Date of Filing:

1. The complaint should include: a summary of the events giving rise to the grievance, important dates, and the identities of key decision makers and witnesses; a summary of the steps, if any, that the Grievant has already taken to resolve the problem; an explanation as to why the matter is grievable under this policy, including a citation to any policies or supporting procedure that may have been violated; a description of the remedy or requested resolution that the Grievant believes is appropriate; and any correspondence, documents, recordings, or other evidence that may have a bearing on the matter.

2. All records and information related to grievance proceedings under this Policy (both formal and informal) shall be kept confidential to the degree permitted by law. The Faculty and Staff Grievance Committees, parties to the grievance, and other relevant administrators and faculty (including witnesses and adhoc panel members) shall respect the confidentiality of information and records and the privacy of all parties whose interests are affected by a grievance.