Indiana University
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| 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 ____________________________________________________________________________ |
| 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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Signature of Grievant: _____________________________________________
Grievant's Representative: _________________________________________
Address: ___________________________________________________________
Phone: _____________________________________________________________
UNIVERSITY HUMAN RESOURCE SERVICES
Last updated: 2 February 2006
URL: http://www.indiana.edu/~uhrs
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