Member Concern Information Sheet
Please fill this out to the best of your ability. If you require assistance, please contact your Grievance Chair or the Union Office.
Today's Date *
MM
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DD
/
YYYY
Member's Name *
Unit *
School/Work Place *
Who is involved? (complainant, administrator, supervisor, witnesses, etc.) *
When did it happen? (Date and time) *
Where did it happen? (Be specific) *
What happened? (What did the administrators/supervisor do or not do to give rise this complaint?)
What is the contractual violation or POPPs policy that was violated? If unknown, leave blank. (Contract articles, POPPs policies)
What is the remedy to the situation? If unknown, leave blank.
List any additional information you may need:
Action Taken: (Dates of informal conference(s), first formal step of the grievance process (see Article III of the appropriate contract), complaint discussed with grievance chair, etc.)
Additional Notes:
Form Completed By: *
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