NON

NON-FACULTY GRIEVANCE FORM

Please complete this form in its entirety, including attachments requested, and return it to the Chair of the Grievance Committee. Remember to sign and date the form at the bottom. Thank you.

DATE SUBMITTED: DATE RECEIVED/BY:

TO: UNIVERSITY GRIEVANCE COMMITTEE:

NAME OF PETITIONER:

HOME ADDRESS:

TELEPHONE NUMBER (WORK):

TELEPHONE NUMBER (HOME):

DEPARTMENT/DIVISION:

IMMEDIATE SUPERVISOR:

THE BEST TIME TO CONTACT YOU AND AT WHAT PHONE NUMBER:

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Individual(s) against whom this grievance/complaint is being filed. Include the name(s) and the department(s)/division(s) of each. (You may attach a separate piece of paper if necessary.)

________________________________________________________________________

Nature of Grievance – Please describe the relevant facts, circumstances and reasons you wish to file a grievance. Include dates, details and if possible, copies of any documentation in regards to grievance. (You may attach a separate piece of paper if necessary.)

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Please state which Creighton University Policy(s) or Procedure(s) or the application of policies or procedures are at issue. The Creighton University Guide to Policies and Procedures is available for check out at all the Creighton University Libraries (Reinert, Law and Health Sciences) at the circulation desk. Or you may access the Guide to Policies and Procedures through the Creighton University website at: http://www.creighton.edu/President/PresOfc/GuideToPolicies/index.html. (You may attach a separate piece of paper if necessary.)

________________________________________________________________________

Statement of Desired Outcome (should be realistic):

________________________________________________________________________

Attach any supporting documentation and evidence in regards to your case.

________________________________________________________________________

Please list the name(s), telephone number(s), and department(s) of witnesses who have knowledge or information relevant to the grievance. Please include the relations/reason to contact each person.

Also include names of witnesses whom desire to be called in support of the position of the grievant. (You may use a separate piece of paper if necessary.)

Signature: ____________________________________________

Date: _______________________________________________

This form is available to download and complete at the Grievance Committee website (http://www.puffin.creighton.edu/grievance/). You may mail the Grievance Form to the Chair of the committee:

Jim Bothmer
Chair of the Grievance Committee 2007/08
Director, Health Sciences Library/Learning Resources Center
Creighton University
2500 California Plaza
Omaha, NE 68178
jbothmer@creighton.edu
VOICE: 402/280-5120
FAX: 402/280-5134