County of San Diego

GRIEVANCE FORM

The purpose of the grievance procedure is to provide a just and equitable method for the resolution of grievances as quickly as possible without discrimination, coercion, restraint, or reprisal against any employee or management representative who may be involved in a grievance procedure or its resolution.  Before filling our this form, consult the grievance procedure provisions applicable to your bargaining unit regarding time limits and other requirements.

  I verbally notified my supervisor of my complaint and the remedy sought on _________________(date)

                                                                                                                                                                                                                                                                          Employee's name (print)                                                                 Employee's Signature                                                        

 Work Phone: _______________________                 Department: ___________________

Division: __________________________                  Classification: _________________

Date Delivered to Supervisor: _____________________________

Representative (if any):__________________________________

Bargaining Unit: _______________________________________

DESCRIPTION OF GRIEVANCE

1. What happened:

2. When did it occur, or when did you find out:                                                    

3. Was a specific section of the Memorandum of Agreement violated; if so, what section? 

4. Remedy sought:

Date received by Supervisor: ____________________________________

Supervisor's written response:

Supervisor's signature:                                                              

Date delivered to employee:                                                 

Date received by employee:                                                     

I am forwarding this grievance to the next step:  ________________________________

                                                                                                        Employee’s Signature

Date delivered to Middle Management:  __________________________________

Representative’s Signature (if any):  _____________________________________

Grievance delivered to: ___________________________________

Signature:  _____________________________________________

Date received by Middle Management:  _______________________________________

Middle Manager’s written response:

Middle Manager’s Signature:  _______________________________________

Date delivered to Employee:  ________________________________________

Date received by Employee: ____________________________________

I am forwarding this grievance to the next step:  _________________________________

                                                                                                        Employee’s Signature

Date delivered to Department Head:  ____________________________________

Representative’s Signature (if any):  _____________________________________

Grievance delivered to: ___________________________________

Signature:  _____________________________________________

Date received by Department Head:  _______________________________________

Department Head’s written response:

Department Head’s Signature:  _______________________________________

Date delivered to Employee:  ________________________________________

Date Received by Employee: ________________________________________

NOTE TO EMPLOYEE:         If you wish to pursue the grievance further, please consult the grievance procedure provisions applicable to your bargaining unit.

I wish to pursue this grievance further using the procedure for my bargaining unit.

____________________________________                        ________________________

Employee’s Signature                                                               Date