Professional Documents
Culture Documents
Local____________
Date___________
Grievant (s)_____________________________________
Officer/Rep___________________________________
Phone # _______________________
Date of Violation ____________
_____________________________________________________________________________
_____________________________________________________________________________
Background/Facts of the Case________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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Unions Position: List the elements of just cause we believe the employer has violated and the relevant proofs.
Reasonable Rule:___________________________________________________________________________________
Proof: ________________________________________________________________________
Notice: ___________________________________________________________________________________________
Proof:_________________________________________________________________________
Fair and Sufficient Investigation_______________________________________________________________________
Proof:_________________________________________________________________________
Evidence of Misconduct: ____________________________________________________________________________
Proof:_________________________________________________________________________
Equal Treatment: ___________________________________________________________________________________
Proof:_________________________________________________________________________
Appropriate Discipline: ______________________________________________________________________________
Proof:_________________________________________________________________________
THIS FORM MUST BE COMPLETED PRIOR TO FILING THE GRIEVANCE FOR ARBITRATION.
_____________________________________________________________________________
_____________________________________________________________________________
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Employers Position: List the elements of just cause the employer bases the discipline on and their proofs:
Reasonable Rule:___________________________________________________________________________________
Proof: ________________________________________________________________________
Notice: ___________________________________________________________________________________________
Proof:_________________________________________________________________________
Fair and Sufficient Investigation_______________________________________________________________________
Proof:_________________________________________________________________________
Evidence of Misconduct: ____________________________________________________________________________
Proof:_________________________________________________________________________
Equal Treatment: ___________________________________________________________________________________
Proof:_________________________________________________________________________
Appropriate Discipline: ______________________________________________________________________________
Proof:_________________________________________________________________________
In file
Not Applicable
Grievance Form:
Grievance Decision letters:
Discipline Notice:
Personnel File (relevant info):
Applicable Facility Policies:
Complaints/letters:
Patient Chart:
Witness statements:
THIS FORM MUST BE COMPLETED PRIOR TO FILING THE GRIEVANCE FOR ARBITRATION.
Witness Statements (Please provide additional names on a separate sheet if needed. Attach full statements to file):
#1 - Name _________________________________________
Date ____________________
Date ____________________
Date ____________________
Date ____________________
THIS FORM MUST BE COMPLETED PRIOR TO FILING THE GRIEVANCE FOR ARBITRATION.
Yes
No
Approve
Disapprove
Date _________________
If disapproved, date of letter to grievant regarding LEB Decision and their right to appeal to SEC: _____________
Signature of Grievance Chair __________________________________
Date________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Weaknesses:
________________________________________________________________________________________
___________________________________________________________________________________
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___________________________________________________________________________________
Signature of Staff Representative_______________________________
Date________________
THIS FORM MUST BE COMPLETED PRIOR TO FILING THE GRIEVANCE FOR ARBITRATION.
THIS FORM MUST BE COMPLETED PRIOR TO FILING THE GRIEVANCE FOR ARBITRATION.