Employee

Grievance	U.S. Department of Housing

and Urban Development

Employees must use this form to file grievances at steps 2 and 3 of the grievance procedure.

Use of this form is optional at step 1.

Check one of the boxes:	Step 1	Step 2	Step 3

Name of Grievant:	Office Code:	Duty Phone:

Name of Union Representative (if any):	Office Code:	Duty Phone:

Briefly describe the incident-causing grievance. Include date, time, and place, management officials involved, if any:

Identify the article(s) or section(s) of the master agreement / local supplement, law or regulation alleged to have been violated:

Identify the remedy you seek:

Questions and/or further correspondence in this matter should be sent to the union representative and the grievant.

The employee bears the responsibility for meeting all time limits for the filing and appeal of this grievance.

Attach a copy of the record of the grievance discussion, it any.

Signature of Grievant & Date:

X	Acknowledgement of receipt by Management (if personally delivered)

Signature & Date:

X
If your grievance is not resolved to your satisfaction, you may submit the grievance to the next step of the grievance procedure by signing and dating this form (at right) and attaching a copy of management’s reply. Any additional information you believe is pertinent should also be attached.	Signature of Grievant & Date:

X
form HUD-25016 (2/2003)

Telephone

ed kapfer

2003-02-13

ATS