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Summary of Complaint
1. Date of Incident: ?
2. Time of Incident:
3. Location of Incident:
4. What happened that caused you to contact the union?
5. Is this a repeat occurrence (Check one): Yes No
If yes, please provide the date and time of the first offense:
6. What did you see? Who said what? What specific actions were taken and by whom? (List in chronological order; you may attach additional paper.)
7. Are there any witnesses involved? (Check one): Yes No
If yes, please provide their information below:
8. Is there any evidence besides statements and recollections? (Check one): Yes No
If yes, please list and attach copies of all documentation.
9. Have you lost anything you already had? (Check one) Yes No
Explain:
10. Have you lost something you would have already had? (Check one): Yes No
Explain:
11. How have all or any of these events harmed you?
12. Have you already discussed this with anyone in management (Check one): Yes No
If yes, please provide details:
13. Has any other employee been harmed similarly by these management actions? (Check one): Yes No
If so, who are they? May we contact them?
14. What remedy do you want or what will make you whole again?
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I, (Enter Name), hereby state that I wish to file a formal grievance with the American Federation of Government Employees Local No. 12, AFL-CIO.
I understand that it is my responsibility to provide all necessary or required information to facilitate adequate representation.
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