Statement of Complaint. Staff Name: Program: Supervisor: Date of Discipline in question: Date: Job Title: Shift: Issued by: Why do you feel that you should not have received this discipline? Is this discipline a violation of a written policy or procedure? (check one) □ Yes □ No If yes, briefly describe the written policy or procedure or if appropriate attach a copy. Section(s) of the contract violated or misinterpreted: Article # Section # Page # What specifically do you think should be done? Are there any witnesses who can support your position? (please include names and programs they are assigned) What is the best time and way to get in contact with you? (please include a phone number) Employee Signature Date Union Xxxxxxx Signature Date Grievance Procedure Form Disciplinary Grievances Step 1 – Human Resource or Designee: (Respond by ) (Within 14 calendar days) Decision: (Please see attached memo.) Human Resources Signature Date Employee Response: (Forward to Human Resource within 14 calendar days after Human Resources responds). Do you wish to have this grievance taken to the next step? □ Yes □ No Please indicate your reason to pursue to the next step? Employee Signature Date Union Xxxxxxx Signature Date
Statement of Complaint. The following is a summary and statement of the facts which the Complainant believes support the issuance of a formal ethics complaint by the ISA. This factual statement must include a clear explanation of the alleged unethical certificant/candidate’s conduct. The statement need not include all of the evidence the Complainant is prepared to present; however, the Complainant must explain the facts in sufficient detail to permit the certificant/candidate Respondent to answer the allegations. If the space below is not sufficient, additional pages may be used and attached.
