APPENDIX Q COUNTY GRIEVANCE FORM

Montgomery County, Office of Labor Relations
Grievance Form for County Grievance Procedure

FILING INSTRUCTIONS — For more information about the County Grievance Procedure, contact the Labor/Employee Relations Team on 240-777-5114, review Section 34 of the County Personnel Regulations [COMCOR 33.07.01.34], or go to Section 34 at

https://www.montgomerycountymd.gov/HR/Resources/Files/Regulation/MCPR%202001%20Section%2034.pdf .

1.   Complete this form and give a copy, along with any supporting documentation, to your supervisor. Failure to provide your supervisor with a copy of your grievance may delay the process. Send one copy and any attachments to the Office of Human Resources, Labor/Employee Relations Team, 101 Monroe Street, Rockville, MD 20850.

2.   Do/Will you have representation? If so, please provide   name:_________________________

   mailing address: ______________________________   phone no.:_____________________

3.   Would you be interested in Alternative Dispute Resolution?    Yes ___   No ___

Failure to provide complete information may delay the processing of your grievance.

FILING INFORMATION: (Please Print Clearly)

Employee’s Name: _______________________________ Position Title:_____________________ Grade: _____

Department/Division/Section:__________________ ________ Immediate Supervisor: ______________________

Home Address: ____________________________________________________________________________ __

Phone: Home:__________________ Work:_________________ E-mail address:__________________________

GRIEVANCE STATEMENT — You must cite the specific written policy, regulation, or treatment in which you believe a violation or inequity occurred. Please attach additional information if more space is needed. Failure to provide complete information may delay the processing your grievance.

RELIEF REQUESTED

Employee’s Signature: _______________________________________ Date: ____________________

DEPARTMENT/SUPERVISOR INFORMATION. In order to respond to the employee’s grievance, please complete the Grievance Response Form, which can be obtained from OHR, Labor Relations Team or online at the OHR Resource Library.