Name              Job Title                                            

Signature                    Date                                                 

Home Address       City        State        ZIP                  

Home Phone                                                            Personal Cell Phone                                                   

Age (if relevant)                                                                      Sex (if relevant)                                                    Race (if relevant)        

Business Unit      Work Location                                                                

   Seniority Date           Supervisor                                                                                            

Work Phone                                                                      Weekly Rate of Pay                                                       

Date given to Steward                                                                       Steward     

Date of contract violation or events causing grievance       

Contract article(s) or other agreements grieved                      

1. What are the events leading to the grievance (FACTS only)?  Include where and when the events occurred and who was involved (including their titles).  Attach additional pages, if necessary. 
2. Why, in the grievant’s or the steward’s opinion, did the incident occur?                                                                                                                                                                                                             
3. What remedy is appropriate?                                                                                                                                                                                                                                                                                                                                     
4. List the names of all people (other than the ones already named) who would have information concerning the grievance.                                                                                                                             
5. Have the facts involved in the grievance occurred previously? If so, state where and when and whether a grievance was filed.                                                                                                                   
6. If this grievance involves discipline, list previous warnings and suspensions the Company has given the grievant. List the dates of this previous discipline and the nature of the conduct for which the grievant received the discipline. Also, if other employees have received lesser or no discipline for the same or a similar offense as the one described in this grievance, list the names of those employees, explain their offenses, describe the penalties they received (if any), and give the dates of their offenses.