Kaiser Permanente

Grievance Withdrawal Request Form

Date:	Select date

To:	Click here to enter text.

From:	Click here to enter text.

The Union is requesting a grievance withdrawal on behalf of:

Grievant: Grievant first and last name

Job Classification: Employee’s job classification

Center: Name of center

Department: Name of department

Grievance filed: Click here to enter text.

Date grievance filed: Select date

☐ 1st Step: Outcome

☐ No meeting held: Reason(s)

☐ 2nd Step: Outcome

☐ No meeting held: Reason(s)

cc:	Sarah Levesque, Staff Representative, OPEIU Local 2

Sandy Smith, Contract Specialist

Grievant first and last name

Head Steward first and last name