NAME:

SOCIAL SECURITY #:

SENIORITY DATE:

TITLE:

LENGTH OF TIME IN TITLE:

SUPERVISOR'S NAME:

WORK ADDRESS:

WORK TELEPHONE:

DEPARTMENT:

HOME ADDRESS:

HOME TELEPHONE:

HOME EMAIL ADDRESS:

INCIDENT DATE:

WHO WAS INVOLVED:

SITUATION CAUSING GRIEVANCE: (include supporting documentation/information). Please be as specific with time, date,
who, when, where, etc. as you can.

HOW DID THIS AFFECT YOU?:

WHAT ARE YOU LOOKING FOR AS A SETTLEMENT:

DATE: