Grievance: Employee Appeal Level One

Date Received

MonthDayYear
Date
Exhibit B: Employee Grievance

DGBA (LEGAL) & (LOCAL)
Optional Apepal

To Central Office Office Administrator

This form must be filled out completely by an employee appealing a Level One decision to the Superintendent or designee in accordance with the District’s policy DGBA (Legal) & (Local). To appeal a Level One decision, please fill out this form completely and submit it by hand delivery, fax, e-mail or U.S. mail to the Superintendent or designee within the time established in DGBA (Local). Appeals must be filed within 20 days of receiving a written decision. Please be advised that the only remedies ruled upon shall be those listed in the Level Two Grievance Form. Remedies requested in an oral manner at any hearing level shall not be considered. At the discretion of the hearing officer, you shall be afforded a reasonable amount of time to present your grievance.
Name*
Employee ID*
Address*

Address

Street Address Line 2

CityStateState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Position/Assignment*
Campus/Department
If you will be represented, please identify the person representing you.
Name Organization
Address

Address

Street Address Line 2

CityStateState / Province

Postal / Zip Code
Phone
Email
example@example.com
1) To whom did you present your grievance at Level One?
Date conference was held: *

MonthDayYear
Date
2) Date you received the written response to the Level One Conference:

MonthDayYear
Date
3) Why do you disagree with the Level One response? Please explain in detail. Specifically list the remedy or remedies requested, but not granted, at Level One.
Grievant, please note:

A grievance form that is incomplete in any material may be dismissed, but may be re-filed with all the required information if the re-filing is within the designated time for filing a grievance. Attach to this form any documents you believe will support the grievance. Please keep a copy of the completed form and any supporting documentation for your records. If established by policy, a review or appeal of a grievance must be conducted by a person with the authority to address the grievance unless a preliminary hearing is necessary to develop a record or a recommendation for the board of trustees of the school district. Please be advised that a grievant is allowed to add claims or documents during the grievance process. However, the grievance may be remanded to a lower level in order to develop the record, if necessary. Please be advised that the only remedies ruled upon shall be those listed in the Level Two Grievance Form. Remedies requested in an oral manner at any hearing level shall not be considered. At the discretion of the hearing officer, you shall be afforded a reasonable amount of time to present your grievance.
Employee Signature*

Clear
Print Name*
Date of Filing*

MonthDayYear
Date
Signature of Employee's representative

Clear
Print Name
Date

MonthDayYear
Date
Superintendent's/Designee's Signature

Clear
Print Name
Date Received

MonthDayYear
Date
Form No. 903-027 Revised 08/2025
Should be Empty: