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HPAE GRIEVANCE WORKSHEET - DISCIPLINE

Local____________

Date___________

Number (optional) _______

Grievant (s)_____________________________________

Arbitration Filing Deadline __________

Officer/Rep___________________________________

Date of Hire __________ Job Title _________________ Unit ____________


Contract section (s) violated__________________________________

Phone # _______________________
Date of Violation ____________

SECTION 1 BASIC ISSUES, FACTS, AND ARGUMENTS


Issue_____________________________________________________________________________________________

_____________________________________________________________________________
_____________________________________________________________________________
Background/Facts of the Case________________________________________________________

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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_____________________________________________________________________________
_____________________________________________________________________________
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Unions Position: List the elements of just cause we believe the employer has violated and the relevant proofs.
Reasonable Rule:___________________________________________________________________________________
Proof: ________________________________________________________________________
Notice: ___________________________________________________________________________________________
Proof:_________________________________________________________________________
Fair and Sufficient Investigation_______________________________________________________________________
Proof:_________________________________________________________________________
Evidence of Misconduct: ____________________________________________________________________________
Proof:_________________________________________________________________________
Equal Treatment: ___________________________________________________________________________________
Proof:_________________________________________________________________________
Appropriate Discipline: ______________________________________________________________________________
Proof:_________________________________________________________________________

THIS FORM MUST BE COMPLETED PRIOR TO FILING THE GRIEVANCE FOR ARBITRATION.

Remedy sought: Made whole in every respect including: ___________________________________________________

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Employers Position: List the elements of just cause the employer bases the discipline on and their proofs:
Reasonable Rule:___________________________________________________________________________________
Proof: ________________________________________________________________________
Notice: ___________________________________________________________________________________________
Proof:_________________________________________________________________________
Fair and Sufficient Investigation_______________________________________________________________________
Proof:_________________________________________________________________________
Evidence of Misconduct: ____________________________________________________________________________
Proof:_________________________________________________________________________
Equal Treatment: ___________________________________________________________________________________
Proof:_________________________________________________________________________
Appropriate Discipline: ______________________________________________________________________________
Proof:_________________________________________________________________________

SECTION 2 INFORMATION AND DOCUMENTS


Information Checklist:

In file

Requested But Not Provided

Not Applicable

Grievance Form:
Grievance Decision letters:
Discipline Notice:
Personnel File (relevant info):
Applicable Facility Policies:
Complaints/letters:
Patient Chart:
Witness statements:

Grievant Previous Disciplines:


If there are previous disciplines, list by date, level of discipline, and result of grievance
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

THIS FORM MUST BE COMPLETED PRIOR TO FILING THE GRIEVANCE FOR ARBITRATION.

Information requests to management (Include requests and responses in file):


#1 Sent to _____________________ Date ________ Information requested ______________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
#2 Sent to ______________________ Date ________ Information requested _____________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

Witness Statements (Please provide additional names on a separate sheet if needed. Attach full statements to file):
#1 - Name _________________________________________

Date ____________________

Summary of statement: __________________________________________________________________________


______________________________________________________________________________________________
______________________________________________________________________________________________
#2 - Name _________________________________________

Date ____________________

Summary of statement: __________________________________________________________________________


______________________________________________________________________________________________
______________________________________________________________________________________________
#3 - Name _________________________________________

Date ____________________

Summary of statement: __________________________________________________________________________


______________________________________________________________________________________________
______________________________________________________________________________________________
#4 - Name _________________________________________

Date ____________________

Summary of statement: __________________________________________________________________________


______________________________________________________________________________________________
______________________________________________________________________________________________

THIS FORM MUST BE COMPLETED PRIOR TO FILING THE GRIEVANCE FOR ARBITRATION.

Any similar, previous grievances or arbitrations?

Yes

No

If Yes, provide date and outcome of the grievances/arbitrations:


#1 - _________________________________________________________________________________________
#2 - _________________________________________________________________________________________
#3 - _________________________________________________________________________________________

SECTION 3 EVALUATION AND DECISION

Reviewed by Local Executive Board

Approve

Disapprove

Date _________________

If disapproved, date of letter to grievant regarding LEB Decision and their right to appeal to SEC: _____________
Signature of Grievance Chair __________________________________

Date________________

Strengths and Weaknesses of the Grievance (To Be Completed by Staff Rep):


Strengths:
_________________________________________________________________________________________

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__________________________________________________________________________________
__________________________________________________________________________________
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__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Weaknesses:

________________________________________________________________________________________

___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Signature of Staff Representative_______________________________

Date________________

THIS FORM MUST BE COMPLETED PRIOR TO FILING THE GRIEVANCE FOR ARBITRATION.

THIS FORM MUST BE COMPLETED PRIOR TO FILING THE GRIEVANCE FOR ARBITRATION.