GRIEVANCE REPORT	

DATE	LOCAL NUMBER	GRIEVANCE NUMBER
MEMBER’S NAME	CLOCK NUMBER
COMPANY
DEPARTMENT	SUPERVISOR
WHEN DID GRIEVANCE OCCUR? DATE (on or about)	TIME
GRIEVANCE REPORTED BY
COMPLAINT
The Union charges the Company with a specific violation of Article (s)
and any other provisions of the Agreement that may be found to apply.
STATE WHAT HAPPENED:
REMEDY
REQUESTED
plus the Union demands that the Company cease and desist from violating the Collective Bargaining Agreement, that the incident(s) be rectified, that proper compensation, including benefits and overtime, at the applicable rate of pay, be paid for all losses; and further that those affected be made whole in every respect, including interest on any monies owed.
SIGNATURE FOR THE UNION	SIGNATURE FOR THE COMPANY
SIGNATURE FOR THE UNION	SIGNATURE FOR THE COMPANY
FORM 122
Grievance Report_1 31 07 indd

DATE

GRIEVANCE PROCEDURE
FIRST STEP
DATE SUBMITTED	STEWARD
ANSWER
SIGNATURE OF COMPANY OFFICIAL
SETTLEMENT SATISFACTORY: YES 0 NO 0	DATE
SECOND STEP
DATE SUBMITTED	STEWARD
ANSWER
SIGNATURE OF COMPANY OFFICIAL
SETTLEMENT SATISFACTORY: YES 0 NO 0	DATE
THIRD STEP
DATE SUBMITTED	STEWARD
ANSWER
SIGNATURE OF COMPANY OFFICIAL
SETTLEMENT SATISFACTORY: YES 0 NO 0	DATE
FOURTH STEP
DATE SUBMITTED	STEWARD
ANSWER
SIGNATURE OF COMPANY OFFICIAL
SETTLEMENT SATISFACTORY: YES 0 NO 0	DATE
ARBITRATION
DATE SUBMITTED TO ARBITRATION
NAME OF ARBITRATOR
DECISION OF ARBITRATOR (attach copy)