FUPOA POLICE OFFICER UNIT GRIEVANCE FORM

FUPOA
POLICE OFFICER UNIT
GRIEVANCE FORM
Allegations of a violation of the Police Officer Agreement in effect between the University and
FUPOA must be filled in on this form. See your Agreement for details regarding the filing of a
grievance. PLEASE PROVIDE THE INFORMATION REQUESTED IN ACCORDANCE WITH
ARTICLE 6, GRIEVANCE PROCEDURE OF THE POLICE OFFICER UNIT AGREEMENT.
GRIEVANT=S NAME
NAME OF GRIEVANT=S IMMEDIATE SUPERVISOR
CAMPUS
DEPARTMENT/DIVISION
EMPLOYEE CLASSIFICATION TITLE
WORK TELEPHONE
NON-WORK ADDRESS TO WHICH CORRESPONDENCE MAY BE SENT TO
GRIEVANT
EMPLOYEE EMPLOYMENT STATUS
c
c
c
Career/Regular
GRIEVANT=S NORMAL WORK SCHEDULE
c
c
Probationary
Casual/Temporary
Full Time
Part Time
IF REPRESENTED IN THIS GRIEVANCE, PROVIDE THE FOLLOWING:
REPRESENTATIVE=S NAME
REPRESENTATIVE=S ORGANIZATION
REPRESENTATIVE=S TELEPHONE NUMBER
REPRESENTATIVE=S ADDRESS, CITY, STATE, ZIP
TYPE OF GRIEVANCE:
c
c
c
INDIVIDUAL
GROUP (LIST ALL GRIEVANTS)
SPECIFIC ARTICLE(S) & SECTION(S) OF THE CONTRACT
ALLEGED TO BE VIOLATED:
UNION (MUST BE SIGNED BY THE
PRESIDENT OR DESIGNEE)
DATE OF ACTION CAUSING GRIEVANCE
DATE OF INFORMAL DISCUSSION WITH SUPERVISOR
_____/_____/_____
_____/_____/_____
DATE OF INFORMAL RESPONSE, IF ANY
_____/_____/_____
ALLEGED VIOLATION OF AGREEMENT
REMEDY REQUESTED
GRIEVANT=S AND/OR REPRESENTATIVE=S SIGNATURE
DATE
GRIEVANCE REVIEW -- STEP 1
DATE STEP 1 GRIEVANCE RECEIVED BY UC
DATE OF UC RESPONSE
STEP 1 DECISION
SIGNATURE OF STEP 1 REVIEWER
PRINTED NAME AND TITLE OF STEP 1 REVIEWER
TELEPHONE NUMBER
? I DO NOT ACCEPT AND APPEAL THE STEP 1
RESPONSE TO THE SECOND STEP (STATE
SUBJECT BELOW)
GRIEVANT=S AND/OR REPRESENTATIVE=S SIGNATURE
DATE
SUBJECT OF GRIEVANCE AT STEP 2, IF DIFFERENT THAN SUBJECT OF GRIEVANCE AT STEP 1.
GRIEVANCE REVIEW -- STEP 2
DATE STEP 2 APPEAL POSTMARKED/HAND-DELIVERED
SIGNATURE OF STEP 2 REVIEWER
? I DO NOT ACCEPT AND APPEAL THE STEP 2
RESPONSE TO THE SECOND STEP (STATE
SUBJECT BELOW)
DATE STEP 2 APPEAL RECEIVED BY
UC
DATE OF UC
RESPONSE
DECISION
ATTACHED
? YES
? NO
PRINTED NAME AND TITLE OF STEP 2 REVIEWER
GRIEVANT'S AND/OR REPRESENTATIVE'S SIGNATURE
DATE
SUBJECT OF GRIEVANCE AT STEP 3, IF ANY ISSUE(S) OF GRIEVANCE AT STEP 2 HAS BEEN RESOLVED.
GRIEVANCE REVIEW -- STEP 3
DATE STEP 3 APPEAL POSTMARKED/HAND-DELIVERED
DATE STEP 3 APPEAL RECEIVED BY
UC
DATE OF UC
RESPONSE
DECISION
ATTACHED
? YES
? NO
If no, decision
status
SIGNATURE OF STEP 3 REVIEWER
PRINTED NAME AND TITLE OF STEP 3 REVIEWER
________