Grievance Form*

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Name of Employee Position Date of this Report

State your grievance in detail, including the date of act[s] or omissions causing grievance and attach
any supporting documentation:
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____________________________________________ __________________________________
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________________________________ __________________________________________
Identify other GWA & Global staff with knowledge of your grievance: State names & reason for
involvement. These people may be contacted during the resolution process.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________ __________
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Briefly state your efforts to resolve this grievance:
__________________________________________________________________________________
__________________________________________________________________________________
___________________________________________________________________ _________
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Describe any remedy or solutions you propose:
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__________________________________________________ ________________________

Employee's Signature: ___________________________________ Date: _____________________

Step One – No Written Documentation Required – Informal Resolution Attempted

Have you already had a face to face discussion with this individual?
If not, then stop and do so before proceeding!
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Step Two*
Date Received: _____________Actions Taken: _________________________________ ________
By: ________________________________ Comments/Decision: ________________________ __
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Check One: Accepted____ Appealed____

Step Three*
Date Received: _____________Actions Taken: __________________________________ _______
By: ________________________________ Comments/Decision: ___________________ _______
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Check One: Accepted____ Appealed____

Step Four*
Date Received: _____________Actions Taken: _________________________________ ________
By: ________________________________ Comments/Decision: ________________________ __
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Check One: Accepted____ Appealed____

Step Five*
Date Received: _____________Actions Taken: __________________________________ _______
By: ________________________________ Comments/Decision: ___________________ _______
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

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*Please attach all supporting documents.