MDCH Grievance form
DCH Grievance Form
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Michigan Department of Civil
Service |
CS-G1
994 |
Commodity Number
4833-1000 |
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GRIEVANCE PROCEDURE FORM CS
G1 |
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Number
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Department (Agency)
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DISTRIBUTION
White
-
Step 3
Goldenrod
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Step 2
Pink
-
Step 1
Canary
-
Employee
AUTHORITY: In accordance with Article XI, Section, Michigan Constitution of1963 and Public Act 431 of 1984.,
A portion of this information is protected by federal privacy laws and/or confidentiality requirements. |
Occupational Unit
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Class/Level
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Name (print or Type)
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Social
Security Number
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Address
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City
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State
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Zip Code
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Home Telephone
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Work
Telephone
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I discussed my complaint with my supervisor on
and received his oral answer on
. This
answer is unacceptable. I wish to grieve to Step 2. Normally, grievances
must be processed through each of these steps, however, see the reverse side
of this form for special instructions for skipping steps in specified types
of cases.
THIS IS A DIRECT FILING TO:
STEP 2
STEP 3 |
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EMPLOYEE'S STATEMENT OF
GRIEVANCE |
State (cite) the specific rule(s), regulation(s),
policy(ies), condition(s) of employment, personnel law(s), or agreement(s)
involved in the grievance. Provide a complete statement of the
grievance, including the dates, times and places of occurrence of the events
related to the grievance and the persons involved and describe how each
stated rule, regulation, policy, etc., was violated. (Use additional pages
if necessary.)
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NOTE: If at any step of the grievance
procedure the Department fails to answer the grievance within the time
limits prescribed in Section 8-202 of the Grievance and Appeals Procedure or
within the time limits set forth in a written agreement extending the time
limits, it is the responsibility of the employee to appeal to the next step
within fifteen (15) weekdays from the date when the Department's time for
answer expired. Failure to appeal to the next step within the prescribed
time limits may result in the closure of the grievance on the basis of the
last answer. |
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A just and fair solution of my grievance is (use
additional pages if necessary)
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Grievant's Signature
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Date Given Supervisor
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STEP 1 SUPERVISOR'S ANSWER
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Date Received
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Supervisor Signature
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Date Given Employee
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