STEWARD REQUEST FOR GRIEVANCE INVESTIGATION

(Please print clearly)

NAME OF COMPANY: ______________________________Date: __________

1. Date of Incident_________________________________________________

2. Name of Employee ______________________________________________

Address ______________________________________________

Telephone No. _________________________________________

3. Explanation of Incident or Violation (include all dates, names, equipment numbers)

__________________________________________________________________________

__________________________________________________________________________

___________________________________________________________________________

4. Agreement Article(s) _____________________________________________

5. Relief Sought __________________________________________________

______________________________________________________________

______________________________________________________________

Signed: _________________________

Telephone No.: (         ) ______________

EMPLOYER REPLY

Date Received ________________    Reply Date ____________________

1. Investigation Results _____________________________________________

______________________________________________________________

2. Employer Position _______________________________________________

______________________________________________________________

3. Agreement Article(s) _____________________________________________

Signed: _________________________

Title: ___________________________

Directions: Steward completes and signs top of form. Employer or Steward may complete bottom of form. Signed form should be mailed (or brought to Local 70 Business Office) to Local 70 Business Agent.

Rs:opeiu29/afl-cio