Grievance Form

***Please note that the submission of this form does not automatically result in a grievance being filed with the employer, but it will be forwarded to the Lead Steward of CUPE 1764 for the appropriate follow up action. Your department representative, steward coordinator and/or lead steward will be in contact with you to discuss the next steps.***

Date *

Steward's Full Name *

Department *

Steward's Email *

Steward's Contact Number *

Members Full Name *

Department/Division *

Occupation *

Members Contact Number

Members Email

Job Status

• Full-Time
• Part-Time
• Casual
• On-Call

Sick Plan

• STIPP
• Banked Time

Name of Greivor’s immediate Supervisor

Email of Greivor’s immediate Supervisor

Name of supervisor/manager involved during the incident.

Email of supervisor/manager involved during the incident.

Description of the Incident or Concern (please include dates, locations, and all other relevant information)

Names and emails of witnesses involved:

Please describe any actions you have taken to address the incident, such as discussions with your supervisor, HR, or union reps. If possible, please forward any emails/correspondence to chiefsteward@cupe1764.ca

What is the employer contending occurred?

Has there been any discipline already issued by management

Which specific article(s) of the collective agreement or regional policy do you believe were violated? Please provide details

What is your preferred resolution/redress to this specific matter

Declaration: I hereby confirm the information provided above is true and accurate to the best of my recollection. I understand that the information provided will be treated confidentially and only be used for the purpose of addressed a potential grievance. *

• Yes

Submit