KAISER PERMANENTE GRIEVANCE REPORT FORM

Grievant (Name): __________________ Tel # (H) ____________ Date ________

 or OPEIU Local 2: _________________ Tel # (W)____________

Center: _______________Department: ______________ Job Title: ____________

Name of Employee’s Supervisor: ________________ Shop Steward: ____________

Article(s) Violated: _____________________________________

Date of Occurrence ___________

Grievance: ____________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Remedy ___________________________________________________________________________

See Attached ___________     Grievant/Steward Signature ________________________________

First Step Meeting Date ________ Decision ________________________________________________

__________________________________________________________________________________

Employer Representative _________________            Union Representative ________________________

Second Step Meeting Date _________              Decision ___________________________________

__________________________________________________________________________________

Employer Representative _________________            Union Representative ________________________

Arbitrate _________________

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: __________________________________________