Kaiser Permanente

Grievance Report Form

Date: Select date

☐ Grievant: Grievant first and last name

Telephone number: Select Telephone number

- or -

☐ OPEIU Local 2

OPEIU Local 2: Staff Representative first and last name

Telephone number: Select Staff Representative telephone number

Information of Affected Employee

Job Title: Employee’s job title

Center: Name of center

Department: Name of department

Employee’s Supervisor: Name of employee’s supervisor

Shop Steward: Name of employee’s shop steward

Article(s) Violated:

Click here to enter text.

Any other related or relevant articles, Partnership Principles, Principles of Responsibility and any State or Federal Laws applicable.

Date of Occurrence: Select date

Grievance: Click here to enter text.

Remedy: Click here to enter text.

☐ See number attached documents.

Grievant or Steward signature: _____________________________________

Grievant or Steward printed name: Click here to enter text.

First Step Meeting Date:

Decision:

Employer Representative signature: _____________________________

Union Representative signature: _____________________________

Second Step Meeting Date:

Decision:

Employer Representative signature: _____________________________

Union Representative signature: _____________________________

Arbitrate:	Yes	No

Please circle.

Note: Union signature at each step is only indicative that such step has taken place and does not reflect concurrence in the decision rendered unless so specified in his/her stated position.

Information Request: