GRAMBLING STATE UNIVERSITY
Grambling, Louisiana

UNIVERSITY GRIEVANCE PROCEDURE FORM

The use of this form must comply with the time limits specified by the University Grievance Procedure Action Steps contained in the Staff Handbook.

INSTRUCTIONS: Complete all information requested on this form. If more space is required, attach additional pages. After completing each step of the grievance procedure, a copy should be forwarded to the EEO Officer.

PART I - TO BE COMPLETED BY GRIEVANT/EMPLOYEE              DATE:

EMPLOYEE NAME:        SS#:

JOB TITLE:       DEPT:

GRIEVANCE STATEMENT

State the incident which occurred that led to this dissatisfaction. Describe the incident including dates, places, individuals involved, etc.:

Stats the reason(s) why you are dissatisfied:

State relief sought:

Grievant's Signature:                 

PART II - TO BE COMPLETED BY SUPERVISOR/ADMINISTRATOR AND EMPLOYEE

DECISION OF SUPERVISOR (DEPARTMENT HEAD OR DIRECTOR)

    Supervisor's Signature: _____________________________    Date: ________________

Employee's Response: Place a check mark in the appropriate box

I am satisfied with the answer to my grievance.

I am not satisfied with the answer to my grievance and will deliver this to the next level supervisor for next step.

DECISION OF THE DEAN OR ASSISTANT VICE PRESIDENT

    Signature: _____________________________    Date: ________________

Employee's Response: Place a check mark in the appropriate box

I am satisfied with the answer to my grievance.

I am not satisfied with the answer to my grievance and will deliver this to the next level supervisor for next step.

DECISION OF THE VICE PRESIDENT

    Signature: _____________________________    Date: ________________

Employee's Response: Place a check mark in the appropriate box

I am satisfied with the answer to my grievance.

I am not satisfied with the answer to my grievance and will deliver this to the next level supervisor for next step.

DECISION OF THE PRESIDENT

    Signature: _____________________________    Date: ________________