GWV Complaint Submission Form

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RNs at GWV and GSWB should use this form to submit instances of contract violations and retaliation/discrimination, as well as the following forms: Assignment Despite Objection (ADO) Form, Mandatory Overtime (MOT) Report Form.

Instructions:
1. Please fill out this form completely. If you need a blank copy of the ADO or Mandatory Overtime Report Forms, you can find them HERE: https://linktr.ee/gwvunion

2. You must send any applicable forms AND existing documentation (emails, screenshots, etc) regarding the incident you are reporting via email or text, see question 9. If there is no documentation (ex: a manager verbally threatened you), please be as thorough as possible in answering question #6.

3. You will receive a call and/or email regarding your submission and it is essential that you respond. Failure to respond will result in a delay in resolving your issue.

If you have any questions, please contact your union rep Mary DelPlato at 412-491-6037 or Mary.DelPlato@seiuhcpa.org

1. Full Name *

2. Unit/Department *

3. Personal Email (Non-work email) *

4. Cell # *

5. Why are you filling out this form? (Select all that apply) *

Submit a copy of Assignment Despite Objection (ADO) Form

Submit a copy of Mandatory Overtime (MOT) Form

Report an instance of retaliation

Report an instance of discrimination

Report a Contract Violation regarding wages, scheduling/PTO use, etc

Report a lack of supplies/equipment

Required

6. Please provide a brief description of what happened: *

7. Have you verbally notified your manager of this complaint? *

Yes

8. If other RNs were involved, affected, or witnessed, please list their names here

9. Documentation is required if its available. Please send a picture or scan of any forms or documentation to Mary.delplato@seiuhcpa.org or 412-491-6037 Select which way you will be sending the documentation. *

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