Employee Grievance - Level Three

Date Received

MonthDayYear
Date
Exhibit D: Employee Grievance

DGBA (LEGAL) & (LOCAL)
Level Three Appeal Notice

To Board of Trustees
To appeal a Level Two 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. Appeals will be heard in accordance with DGBA (Legal) and (Local Please be advised that the only remedies ruled upon shall be those listed in the Level Three Grievance Form. Remedies requested in an oral manner at any hearing level shall not be considered. At the discretion of the presiding officer of the Board, you shall be afforded a reasonable amount of time to present your grievance.
Grievant's information (All information is required)
Name*
Employee ID*
Address*

Address

Street Address Line 2

City, StateState / Province

Postal / Zip Code
Email*
example@example.com
Phone*
Position/Assignment*
Campus/Department*
If you will be represented in voicing your appeal, please identify the person representing you.
Type of Representation

Legal CounselRepresentative
Name/Organization
Address

Address

Street Address Line 2

City, StateState / Province

Postal / Zip Code
Phone
Email
example@example.com
Please answer the following questions
1) To whom did you present your grievance at Level Two?*
Date conference was held*

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

MonthDayYear
Date
3) Why do you disagree with the Level Two response? Please explain in detail. Specifically list the remedy or remedies requested, but not granted at Level Two.
4) Do you want the Board to hear this appeal in open session? Please be advised that the Texas Open Meetings Act may prevent the Board from granting a request for open session if the grievance involves a grievance against a District employee or involves student-related information.*

YesNo
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 Three Grievance Form. Remedies requested in an oral manner at any hearing level shall not be considered. At the discretion of the presiding officer of the Board, you shall be afforded a reasonable amount of time to present your grievance.
Employee Signature*

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Print Name*
Date of Filing*

MonthDayYear
Date
Signature of Employees' representative

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Print Name
Date

MonthDayYear
Date
Superintendent's signature/Designee

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Print Name
Date Received

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

Exhibit D: Employee Grievance

Level Three Appeal Notice

Grievant's information (All information is required)

Please answer the following questions