Grievance Form
DeCA
Appendix C

Grievance Form - Step 1                                      (2) Signed Originals - One for Union, one for EMPLOYER
                                                                                (1) Copy for employee

Grievant(s) Name:        Date Filed: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 . January February March April May June July August September October November December . 2003 2004 2005 .
                                                                                                                  
Select one below:                                                                                                         (Please Print)
I hereby authorize AFGE to represent me in this grievance.
or
I desire to represent myself in this grievance.

AFGE's Representative’s Name:
                                            Phone:
Address:


Basis of Grievance (please include known relevant information necessary to understand the grievance in order to
issue a fair decision) (attach other pages as needed: The grievant is filing a grievance because:




Remedy Sought: (attach other pages as needed)


Does the Grievant request a meeting before a decision is made?  Yes  No
Signature of Grievant:

Receipt of acknowledged (Immediate Supervisor)
Date:

Date of Step 1 Grievance Decision:
Deciding Officials Signature: 

Decision: (attach other pages as needed)

Date received by Representative:
Signature of Representative: