CWA Local 3176

Statement of Occurrence

First Name:

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Last Name:

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Employee ID:

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Address:

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City, State:

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Postal Code:

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Personal E-Mail Address:

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Personal Phone:

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Employer:

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Work Phone:

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Work Location

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Seniority Date

NCS (Hire) Date

Department

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Job Title

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Supervisor's Name

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Supervisor's Phone Number

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Supervisor's E-mail Address

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Witness#1 (Name/Title/Contact#)

Witness#2 (Name/Title/Contact#)

Witness#3 (Name/Title/Contact#)

Witness#4 (Name/Title/Contact#)

GIVE A COMPLETE STATEMENT OF FACTS CONCERNING THE GRIEVANCE CONDITION THAT EXISTS

The following is a statement of what happened to me

(Date of Violation: ) *required

I hereby give consent to the inspection by any authorized Union Representative of any records kept by the Company which may affect the conditions of my employment, which may include Security Reports, Medical Records or Opinions, Police Reports, Court Records or Reports, or any other information which may be relevant and necessary to allow the Union to protect my rights under the Working Agreement between the Union and the Company. This authorization is given in accordance with the existing agreement between the Union and the Company. I also consent to my 'typed signature" as my electronic signature for this grievance in accordance with the E-SIGN act of 2000 to start the initial process of this grievance, but I understand that I must physically sign the grievance form with the processing Steward before progressing beyond the informal step of the grievance process.

Signature:

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