Date___________________ Grievance Number ________________
Type of Grievance ____________________ I.D. Number___________________________
Grievant________________________________________________________________________
Address________________________________________________________________________
Phone_(_____)__________________ Seniority Date___________________________________
Social Security # _______ / _____ /________
Job Title_________________________________Department_____________________________
Immediate Supervisor_________________________ Superintendent______________________
What happened? (Describe incidents which gave rise to the grievance)______________________
______________________________________________________________________________
______________________________________________________________________________
When did it occur? (Give day, time, date(s)____________________________________________
______________________________________________________________________________
______________________________________________________________________________
Who was involved? (Give names and titles)____________________________________________
______________________________________________________________________________
______________________________________________________________________________
Where did it occur? (Specific locations)_______________________________________________
______________________________________________________________________________
______________________________________________________________________________
Why is this a grievance? (What is management violation? e.g., contract, rules and regulations, unfair
treatment, past practice, local, state, or federal laws, etc.)________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
What adjustment is required? (What must management do to correct the problem)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Additional comments (Include the position of the union)__________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Supervisor’s statement (Include the position of the company)______________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Signature of Steward_________________________________________
Date___________________________________
NOTE: A copy of this form is to be completed by the steward filing the grievance and is to be
placed in the grievance file along with a copy of the grievance and disposition. Additional facts may be
enumerated on attached sheets.