Grievance Intake Form

First name

Enter your first name

Last name

Enter your last name

Enter your email

Phone

Enter your phone number

Position

What is your title?

Date of Event

Management Official Full Name

Who is the Grievance being filed against?

Title of Management Official

Example: Supervisor, Nurse Manager, Service Chief, ect.

Describe What Happened

Enter a brief, consice description of the event.

Violation

What articles of the Master Agreement do you beleive are in violation?

Resolve

What resolve would you like to achieve?

Have you filed an EEO or Whistleblower complaint related to this issue?

Yes

Do you have a history of prior discipline?

Yes

If yes, please explain

Include the dates and nature of the disciplinary actions

Upload any evidence you may have

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