Grievance Form, Appendix A MASTER CONTRACT

APPENDIX A


GRIEVANCE FORM


_________________________
Number


_________________________
Level 2: Date Filed


_________________________
Level 3: Date Filed


Lewis Central Community School District

___________________________________Building Distribution of Form:
1. Association
__________________________________________ 2. Employee
Date of Informal Step Meeting 3. Appropriate Supervisor
4. Superintendent
__________________________________________
Name of Employee Making Claim



LEVEL ONE (Informal)

LEVEL TWO (Formal)


A. Date Alleged Violation Occurred __________________________________________________________

B. Section(s) of Contract Violated ___________________________________________________________

C. Statement of Grievance __________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

D. Relief Sought __________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________



_________________________________________________ _____________________
Aggrieved Signature Date


E. Disposition by Principal or Immediate Supervisor _____________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Accepted _______ Rejected _______ ____________________________ __________________
Signature of Principal Date
or Immediate Supervisor


LEVEL THREE


A. ___________________________________________________________________________________
Signature of Aggrieved Person + Date Signed Date Received by Superintendent

B. Disposition by Superintendent ____________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________



LEVEL FOUR



A. __________________________________________ ___________________________________
Signature of Aggrieved Person Signature of Association President



B. __________________________________________