Policy 4120F - Uniform Grievance Procedure

Uniform Grievance Procedure

Concern You Would Like Addressed

(Please keep your presentation to one sheet. Thank you.)

Name:                                                                                         Date:                                                  

Mailing Address:                                                                                                                                  

Phone Number(s):                                                                    

Subject:                                                                                                                                              

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

Problem:                                                                                                                                             

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

Examples that validate the problem:                                                                                                  

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

Results:                                                                                                                                              

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

Suggested Solutions:                                                                                                                          

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

Response Date:                                                                             

Person Responding:                                                                     

Response to Concern

 

Person Responding: ______________________________   Response Date: ____________

Method used to communicate response:                                                        

 

Actions Taken to Investigate Concern:                                                                                              

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

People contacted in gathering information upon which to make decision:                                       

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

Findings of the Investigation:                                                                                                            

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

Decision:                                                                                                                                            

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

Results of communicating the decision:                                                                                            

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

 

                                                                                                                                         

Signature of Respondent                                                         Date