CWA Local 7800

STATEMENT OF OCCURRENCE

Name: ________________________ Seniority Date: __________________________
Home Address ________________________ Wage Rate: __________________________
________________________ Job Title: __________________________
SSN: ________________________

Work Location:

 __________________________

Home #

 ________________________ Department: __________________________
Work#: ________________________ Manager: __________________________

Grievance Type (check one)

q         Warning

q           Dismissal             q          Suspension q           Other

The following is a statement of what happened to me on: __________________, 2008

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Desired Outcome: ______________________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Please complete both forms.

Initials:____________

Reviewed with Member:

 Initials:

Date:

Comments

Initials

Date

Comments

 

 

 

   COMMUNICATIONS WORKERS OF AMERICA

Malachy Sreenan, President CWA LOCAL 7800
Stan Wylie, Executive Vice President 2122 3d Avenue
Debbie Stevens, Secretary/Treasurer Seattle, WA  98121-2306
Bill Haag, Vice President Office:  (206) 441-7800,  1-800-662-4079
  Fax:  (206) 441-8789, Voice Mail:  (206) 441-8977
I
_________________________________________________________,                                                                           GRIEVANT NAME
 

 

hereby request and authorize the Communications Workers of America Local 7800 to represent me and to carry this matter up to and including arbitration.

I further permit any authorized union representative to inspect and make copies of my:
Ø
Personnel file, including any secondary personnel file
Ø
 Any other records kept by the employer which may affect the conditions of my employment.
 
I understand that it is my responsibility to keep CWA Local 7800 informed of my current address and telephone number as this matter is pursued.
 
I am providing this Statement of Occurrence in order to assist CWA Local 7800 in its investigation of a grievance.  I understand that this is a confidential statement and that CWA Local 7800 will not disclose this statement to anyone unless ordered to do so by an appropriate arbitrator, court or federal or state agency.

___________________________________
Signature