Form 1502 2 – Fill Out and Use This PDF

Policy #1502

Attachment #2

DHS UNCLASSIFIED SERVICE GRIEVANCE FORM

Unclassified Employees are to refer to the Grievance Procedure for Unclassified

Employees (Policy #1502) before completing this form

Employee Name:_____________________________________ Employee ID#:___________________

Job Title:________________________	Division/Office/Facility:___________________________
Scheduled Work Hours:___________________		Best time to reach you by phone:_____________
Work Telephone #:_______________________		Home Telephone #:________________________
Can you receive material by fax?_____________________			Fax #:________________________

Employee’s Preferred Mailing Address:___________________________________________________

Street Name or P.O. Box

__________________________________________________________________________________

CityStateZip code [include nine (9) digits]

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Supervisor involved with issue(s): _______________________________________________________

Supervisor’s Telephone #:__________________________

Fax #:________________________

You are encouraged to discuss the non-disciplinary employment concerns with your supervisor

prior to filing a grievance.

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I am filing a grievance and have completed page two (2) of this form. The non-disciplinary employment concerns of my grievance have unfavorably affected my employment. My signature indicates that all of the information contained on the DHS UNCLASSIFIED SERVICE GRIEVANCE FORM and supporting documentation is true and factual to the best of my knowledge.

____________________	___________________________________________________________
Date	Employee’s Signature

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Deliver mail or fax DHS UNCLASSIFIED SERVICE GRIEVANCE FORM and supporting documents to:

OHRMD – Employee Relations Section

28th Floor

Two Peachtree Street, NW

Atlanta, Georgia 30303-3142

FAX #: 404/463-0920

For information or assistance regarding the grievance process, please call 404/656-5807 Monday - Friday / 8:00 a.m. - 5:00 p.m.

Received by OHRMD:		Grievance #:
Form #1502-2	Page 1 of 2		Revised: July 1, 2009

DHS UNCLASSIFIED SERVICE GRIEVANCE FORM (CONTINUED)

	This section must be completed.
DATE ISSUE(S) OCCURRED	LIST ISSUE(S)
[Within Ten (10) Work Days	[Example: Unsafe or Unhealthful Working Conditions]
of Filing Grievance]
__________________________	_______________________________________________
__________________________	_______________________________________________
__________________________	_______________________________________________
__________________________	_______________________________________________
__________________________	_______________________________________________

Additional documents may be submitted for further explanation.

Number of supporting documents attached ___________

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Describe what happened, when and where, and indicate names of others involved in the grievance.

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Are you alleging erroneous, arbitrary or capricious interpretation or application of human resource/

personnel policies or procedures?Yes______No_______

If yes, please specify which ones and how:_________________________________________________

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Requested Relief:_____________________________________________________________________

Employee must send copies of the grievance and supporting documents to the following persons:

_______________________________________________________

Supervisor Involved

_______________________________________________________

Appropriate Human Resource/Personnel Representative

_______________________________________________________

Division/Office Director or Facility Administrator/Superintendent

Form #1502-2

Page 2 of 2

Revised: July 1, 2009