Provost & Academic V.P. Western Illinois University 1 University Circle 211 Sherman Hall Macomb, Illinois 61455 Phone: 309/298-1066 E-mail: PS-Brown@wiu.edu

WIU/UPI Agreement 2001-2005

Appendix C: Board of Trustees
UPI Location 4100
Step One Grievance Form

No.:
Date:

1. Grievant:
2. Home address:                Phone:
3. Office No.:                    Phone:
4. Bargaining unit (check one):
   [ ] Tenured/tenure track
   [ ] ASP/associate faculty
5. College and department/unit:
6. Mailing address--If grievant is represented by the Union, all communication should go to the Union Representative.
7. Provisions of agreement allegedly violated:
   ARTICLE(S)/SECTIONS:
8. STATEMENT OF GRIEVANCE (be specific, include dates of acts or omissions
   complained of):
9. REMEDY SOUGHT:
10. I will be represented in this grievance by (check one):
    [ ] UPI
    [ ] Myself
    Union Representative's signature
    (If Union is representing grievant, the Union Representative should sign here.)
    
    I do [ ] do not [ ] (check one) want a postponement for 30 days to seek informal resolution of this grievance. Any additional postponements must be done in accordance with Article 6.11.b.(1).
11. In accordance with Article 6.2, I understand that this grievance may not be processed if the acts or omissions complained of herein are or become the subject of any other administrative or judicial proceeding, except in cases of discrimination.
12. This grievance was filed with the Academic Vice President's office on:

Received by (check one):
[ ] Certified registered mail, return receipt requested
[ ] Personal delivery--Acknowledgement:

Signature of Grievant             (Month) (Day) (Year)

Revised--Nov. 1996

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