(Please print or type)
Name of Grievant:______________________________	Salary Grade_______________
Grievant's Campus Address:_____________________	Phone:____________________
Grievant's Representative:__________________________________________________
Representative's Campus Address:_______________	Phone:____________________

Department against which grievance is brought:_________________________________________________

Campus Address (if known)________________________________________________

Policy, rule, regulation or specific action of a supervisor alleged to be contrary to University policy: _____________________________________________________________________

Has this grievance been filed with any other University Office?	___ Yes	___ No
If yes, please list the offices and individuals contacted: _____________________________________________________________________

STAGE ONE -		STAGE TWO -
Appealed to:__________________________		Appealed to:_______________________
Date Filed:___________________________		Date Filed:________________________
STAGE THREE - Appealed to: Director, Human Resources Bloomington Campus Date Filed:___________________________		STAGE FOUR - ARBITRATION Date Filed:__________________________ MEDIATION REQUESTED: ___ Yes ___ No LOCAL ARBITRATOR ___ AMER. ARB. ASSN. ___

Use the portion below to describe the nature of the grievance and the remedy requested.

NATURE OF THE GRIEVANCE (Provide a brief description of the alleged act about which the grievance is being filled. Include a statement that indicates how the alleged act is a violation of a University policy, rule, or procedure.)   __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

RESOLUTION REQUESTED (In the space provided, state what remedy you are requesting as a result of the filling of this grievance.)   __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

Grievant's Signature______________________________________

Representative:___________________________________________