The 1199 grievance form is a document used to inform an employer of a problem or complaint an employee has. This form can be used to file a formal complaint or to request assistance with a problem. The 1199 grievance form must be completed in full and submitted to the employer within 30 days of the incident. Employees should keep a copy of the grievance form for their records. The 1199 grievance form is used by employees to inform their employers of any problems they are having with their job or work conditions. This form can also be used as a way to file a formal complaint or request help with resolving an issue. It is important that this form is filled out in full and submitted to the employer within 30 days of the incident. Employees
| Question | Answer |
|---|---|
| Form Name | 1199 Grievance Form |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | seiu district 1199 form, csu seiu 1199, 1199 grievance procedure, seiu 1199 grievance |
CSU/ SEIU DISTRICT 1199
GRIEVANCE FORM
Submit original to management and make four (4) copies and distribute to: (1) Grievant, (2) Chief Steward, (3) Union Staff Representative, and (4) Steward.
EMPLOYEE _________________________________ |
DATE _______________________________ |
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JOB CLASSIFICATION |
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DEPT. ________ |
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SUPERVISOR _________________ |
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DATE OF HIRE ________________________ |
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Summarize nature of grievance. Please specify the basis of the grievance, including all contract violations, University policies, past practices and/or laws, etc. Include all relevant dates.
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(Use additional sheets of paper if necessary.)
DESIRED REMEDY:
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______________________________ and that he be made whole in any and all other respects.
Step 1: Informal Resolution (Discussion with Supervisor) (within 10 working days of the event on which the grievance is based)
Discussion Date: _________Supervisor's Response:
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________________________________________________________________________________________
Step 2: Written Grievance Form to HRD Representative and Department Head or Appropriate Administrator (within 10 working days of the event on which the grievance is based)
Date Filed: ____________________ Meeting Date: ________________
(within 5 working days after filing written grievance) Relevant Information:
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Date Response Received: (within 7 working days of meeting)__________________
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Response:
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Step 3: Written Appeal to Vice President for HRD (within 5 working days after receipt of Step 2
response or within 12 working days after Step 2 meeting if no response is received)
Date Filed: _______________ Meeting Date__________ (within 7 working days after of receipt of appeal)
Relevant Information:
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Date Response Received: (within 7 working days of meeting) _____________________
Response:_______________________________________________________________________________
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Step 4: Written Appeal to Arbitration (Separate form to be filled out for Request for Arbitration. Notice to Vice President for HRD within 10 working days after the next regularly scheduled Union Executive Board Meeting, but no later than 45 calendar days after receipt of the Step 3 response.)
Date Filed: _____________________________Arbitration Date: ______________
Date Response received from Arbitrator: _________________________________
Resolution:
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Mediation (Optional) (All parties may mutually agree to pursue mediation within the 45 calendar day period prior to Arbitration notification in Step 4; the use of mediation must be confirmed in writing; Step 4 notification of intent to arbitrate extended until 21 calendar days after conclusion of mediation, if used.)
Date Requested: ________________________________ Mediation Date: ____________________________
Relevant Information/Resolution ______________________________________________________________
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Unless otherwise indicated, by signing this grievance form, the aggrieved employee grants authorization to the Union to act in his/her behalf and to advance the grievance through the steps of the grievance procedure.
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Signature of Aggrieved Employee |
Date |
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Signature of Union Representative |
Date |
______________ I do not wish the Union to advance my grievance without express authorization.
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