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.
* Required
Today's Date
*
MM
/
DD
/
YYYY
Member's Name
*
Your answer
Unit
*
Choose
Teachers
Para-Educators
Secretaries
Food Service
School/Work Place
*
Choose
Amherst Street
Bicentennial
Birch Hill
Brentwood
Broad Street
Charlotte Avenue
District Office
Dr. Crisp
Elm Street
Fairgrounds Elementary
Fairgrounds Middle
Ledge Street
Main Dunstable
Mt. Pleasant
Nashua High School North
Nashua High School South
New Searles
Pennichuck
Sunset Heights
Who is involved? (complainant, administrator, supervisor, witnesses, etc.)
*
Your answer
When did it happen? (Date and time)
*
Your answer
Where did it happen? (Be specific)
*
Your answer
What happened? (What did the administrators/supervisor do or not do to give rise this complaint?)
Your answer
What is the contractual violation or POPPs policy that was violated? If unknown, leave blank. (Contract articles, POPPs policies)
Your answer
What is the remedy to the situation? If unknown, leave blank.
Your answer
List any additional information you may need:
Your answer
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.)
Your answer
Additional Notes:
Your answer
Form Completed By:
*
Your answer
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