Formal Grievance Form

This form is to be used to file a formal grievance. All four sections must be completed and will serve as the source document for the grievance process (attach additional pages if more room is necessary). Please answer all questions fully. All supporting documentation must be attached to this grievance form at the time the grievance is filed. Additional information may be requested as necessary. ALL filed grievances will be kept confidential.

1. What was the date of occurrence and what specific behavior, condition, or violation of policy or procedure occurred which you consider discriminatory, harassing or unfair / violated your rights?

2. How have you been adversely affected by this situation?

3. What specific action have you taken to follow the guidelines for informal resolution as outlined in the Grievance Procedures for Discrimination and Harassment or the Staff and Administrative Grievance Policy? What has been the outcome of these efforts?

4. What specific remedy do you request?