Staff Complaint/Grievance Filing Form

Contact Information

Your name

Date

Your program/work site and/or position

Preferred contact method(s)

Mail
Email
Phone

Address

Street Address City State / Province / Region ZIP / Postal Code

Email

Phone

Identify Policy Violated

Identification indicates you have received and reviewed policy

Violation of Discrimination Policy 5010
Violation of Sexual Harassment Policy 5011
Violation of Employee Rights Policy 5022
Violation of other policy

Other policy name/number

Incident(s) Background

Date(s) of incident(s) (at minimum, please note first and last date)

Location(s) of incident(s)

Witnesses

Person(s) responsible for policy violation

Incident Description

Please describe what happened in factual detail.

Previous Incidents

Please describe any past incidents that you believe are related to this grievance, including who was contacted and prior attempts to resolve.

Suggested Remedy

Please describe any corrective action you wish to see taken with regard to the possible violation.

Other Information

Please provide other information relevant to this grievance.

Sexual Harassment Review Requested - Policy 5011

An informal review request can be changed to a formal request at a later date or if NWESD 189 believes the complaint needs to be more thoroughly investigated.

Informal (Confidentiality will be protected, if requested, to the extent reasonable.)
Formal (Confidentiality is not possible because of due process requirements; however, the anti-retaliation provisions of Policy 5011 will be fully implemented to protect complainants and witnesses.)

Signature of Grievant

Date

For Office Use

Person Receiving Grievance:

Signature: ______________________________________________

Date: ____________________________________________________

Location: _______________________________

Remitted to NWESD 189 Compliance Officer

Name: ___________________________________________________________

Date: _______________________________