GRIEVANCE COMPLAINT FORM

1.  Name, title, & telephone number of person (s) filing grievance:

2.  Name, title & telephone number of person (s) this grievance is being filed against:

3.  Type of grievance (i.e., salary, working conditions, non-renewal of appointment, etc.).

4.  State the events and/or actions which are the basis of your grievance.  Please include the time, date and location (if applicable) of the events/actions which led to this grievance.  Also, indicate if the grievance is based on one occurrence or is ongoing.  (You may use additional sheets, if necessary).

5.  Summarize your efforts to resolve this grievance.

6.  Please state your desired outcome for this grievance (such as enhanced salary, etc.).

Signature-_____________________________                            Date: _____________________