IUB Grievance Form for Appointed Support Staff Employees

INDIANA UNIVERSITY
GRIEVANCE FORM FOR APPOINTED SUPPORT STAFF
Represented by
COMMUNICATIONS WORKERS OF AMERICA, LOCAL 4730

(Please print or type)

Name of Grievant(s): ________________________ Salary Grade: _____ Dept. Phone: ________

Grievant's
Campus Address: ____________________________ Email: _____________________________

Grievant's Representative:______________________ Phone: ____________________________

Representative's
Campus Address: ____________________________ Email: _____________________________

Department Name and Location of Grievance: ________________________________________

Grievant's
Supervisor: ___________________

Campus
Address:____________________

Email: _______________

Phone: _______________

Department's
Head: _______________________

Campus
Address:____________________

Email: _______________

Phone: _______________

University rule, regulation, policy, procedure, or practice, the specific law, or specified action of a supervisor that is contrary to University policy: ______________________________________

______________________________________________________________________________

Has this grievance been filed with any other University office? Yes No

If Yes, list ALL offices: __________________________________________________________

RIGHT TO REPRESENTATION:
I understand that I have the right to be represented by Communications Workers of America, Local 4730 and that I may choose not to exercise this right. However, I must notify the university at any time that Union representation is being waived. This waiver is irreversible at level 3. See Policy 1.1, Section 6, item (2).
I will be represented by Local 4730. I will not be represented by Local 4730.

Signature of Grievant(s): __________________________________________________________

LEVEL ONE:	LEVEL TWO:
Appealed to: _______________, Supervisor	Appealed to: ___________________, Dean, Director or Dept. Head
Date Filed: _______________	Date Filed: _______________
Grievant requests meeting	Grievant requests meeting Please attach all previous responses and documentation
LEVEL THREE: Appealed to: Employee Relations c/o University Human Resources Bloomington Campus Date Filed: _________________ Please attach all previous responses and documentation. I will be represented by Local 4730 at this and any subsequent step, or I will be represented by myself or __________________ at this and any sub-sequent step. Local 4730 waiver is irreversible at Level 3.	MEDIATION REQUESTED Yes No (excludes cases involving employee termination) Mediation requires mutual consent of both parties. Grievant(s) signature: _________________ Representative(s) signature: ____________ Date requested: _____________________ LEVEL FOUR: ARBITRATION Please attach all previous responses and documentation. Date requested: _____________________ Grievant(s) signature: _________________ Representative(s) signature: _____________

NATURE OF THE GRIEVANCE:

Briefly state what happened, how the action violates a University rule, regulation, policy, procedure or practice, the specific law, or specified action of a supervisor that is contrary to University policy.
Please indicate the date of the incident or the date of your knowledge of the incident.

______________________________________________________________________________

RESOLUTION REQUESTED:

State what remedy you request as a resolution to your grievance. Be specific, please.

______________________________________________________________________________

SIGNATURES:

Grievant(s) Signature: _________________________________ Date requested:_____________

Representative(s) Signature: ____________________________ Date requested:_____________

UNIVERSITY HUMAN RESOURCE SERVICES

Last updated: 22 September 2003
URL: http://www.indiana.edu/~uhrs/
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