Indiana University
Grievance Form for Professional and Non-Union Support and Service Staff

Grievant Name: ____________________
(If there is more than one grievant, please list names
under section NATURE OF GRIEVANCE below)
Department: _______________________
     
Campus Address: _________________ Campus Phone: ___________________
     
Title: __________________________ Classification: _____________________
     
Other Address: ___________________ Phone: __________________________
     
               ___________________  


Policy, rule, regulation or specific action of a supervisor alleged to be contrary to Professional and Support Staff Policy

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STAGE I   STAGE II
     
To: _____________________________   To: _____________________________
(Immediate Supervisor)   (Dean or Director)
     
Department: _____________________   Department: _____________________
     
Date Filed: _____________________   Date Filed: _____________________
     
STAGE III     STAGE IV
     
*To: ____________________________   *Date Filed: ____________________
     
Date Filed: _____________________    


Has this grievance been filed with other University offices? ___ Yes ___ No

If yes, please list the offices and those individuals contacted: _____________
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NATURE OF THE GRIEVANCE
 
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REQUESTED RESOLUTION
 
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Signature of Grievant: _____________________________________________

Grievant's Representative: _________________________________________
Address: ___________________________________________________________
Phone: _____________________________________________________________

Indiana University
UNIVERSITY HUMAN RESOURCE SERVICES

Last updated: 2 February 2006
URL: http://www.indiana.edu/~uhrs
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