Grievance

Form A-HR-16(A)

THREE RIVERS DISTRICT HEALTH DEPARTMENT
GRIEVANCE DOCUMENT

Submit the form to the Director within sixty (60) days of the alleged grievance, per 902 KAR 8:160, Section 12(3). If the grievance is against the District Director, submit the form to Human Resources, which shall submit it to the Board of Health Chairman.

Civil Rights and ADA grievances shall be submitted using form A-HR-16(A) within one hundred and eighty (180) days of the alleged grievance, as per Federal Regulation.

Contents of Grievance

The date the alleged incident occurred.
The location at which the alleged incident occurred.
The employee or contracted agent against whom the complaint is filed.
The description of the alleged incident that occurred.

NOTES: All formal grievances are subject to due diligence and may include investigations, hearings, interviews, fact-finding, development/review of written summaries, and other techniques deemed necessary and acceptable in the grievance process.

Interested and/or affected parties may submit evidence or testimony relevant to the grievance during the investigation.

All federal and state regulations regarding equal employment opportunity shall be followed throughout the grievance process.

Contact Information. If you prefer to remain anonymous, you may skip this question.

Full Name

Workday Employee ID

Is the grievance related to the Director? *This question is required.

Who is the grievance/complaint against? *This question is required.

What is the nature of your grievance? *This question is required.

What have you done to attempt to resolve your grievance? *This question is required.

What do you recommend to resolve the grievance? *This question is required.

Please review Policy A-HR-16 for details on your rights and processes for grievance submission(s).

A written description of the investigation and a description of the resolution shall be issued, and a copy forwarded to the aggrieved employee and the District Director no later than forty-five (45) calendar days after receipt of the formal grievance form.

An aggrieved employee dissatisfied with the resolution may request reconsideration, within thirty (30) calendar days, by the District Director or the Board of Health.

The Personnel Specialist shall maintain a file of all grievances, evidence, and written documentation pertaining to formal grievances filed.