Claim Questionnaire | General Committee II

Claim or Grievance Questionnaire and Submission

Claimant Name

Employee Number

Phone

Address

Company name

What did the company do that violated the rules of the CBA?

Date and time of violation

Month

Day

Year

Time

HoursMinutes

Total Hours Involved?

Is this a continuing claim

Yes

Where did the violation occur? Station, Town, State, Division, District

Why is this a claim or a grievance? List rule violated and your claim

Additional Claimants - Name, Employee ID, Sen. Date, Position, Phone Number

Witnesses- Name, Employee ID, Sen. Date, Position, Phone Number

Supporting evidence of agreement violation

Please list any additional supporting information that is provided with this form. Supporting evidence includes supporting statements, work reports, photographs, etc.

NOTE: The information contained in this form will be used to develop a written claim or grievance. Due to strict enforcement of the time limits provided in our agreement for filing a claim or grievance, you should submit it to your Union representative as soon as possible. If additional space is necessary or if additional documentation and/or information is available, please attach to this form.

Claimant Name

Signature

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Supporting Documents