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Employee Grievance Report Date Reported: Current Date. Employee: First Last Department: Department Supervisor: Supervisor Date / Time Occurred Insert Date and Time of the Grievance. Employee Job Information Position: Contract Job Title Date of Hire: Work Type: Hourly ? Salary ? Shift Type: Day ? Night ? Swing ? Other ? Supervisor must complete the following form and file it with the Human Resources Department.

Description of the Grievance Describe the grievance as well as the events or what happened to cause this grievance. Attach additional pages if necessary.

Witnesses If applicable, did anyone witness the event? Yes ? No ? Name(s) of Witnesses:

Remedy Sought

Supervisor Signature Date

For Office Use Only

Recieved By signator, authorized signature or signer

Human Resources Manager Date