• Statement of Occurrence
    First Name:  * required
    Last Name:  * required
    Employee ID: * required
    Address: * required
    City, State: , * required
    Postal Code:  * required
    Personal E-Mail Address:  * required
    Personal Phone: * required
    Employer: * required
    Work Phone: * required
    Work Location * required
    Seniority Date
    NCS (Hire) Date
    Department * required
    Job Title * required
    Supervisor's Name * required
    Supervisor's Phone Number * required
    Supervisor's E-mail Address * required
    Witness#1 (Name/Title/Contact#)
    Witness#2 (Name/Title/Contact#)
    Witness#3 (Name/Title/Contact#)

    Witness#4 (Name/Title/Contact#)


    The following is a statement of what happened to me (Date of Violation: )

    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:  * required

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  • CWA Local 3176

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