Statement of Occurence (Grievance Form)

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Statement of Occurrence
CWA Local 2100
Union #___________________________ Company # ____________________________
Name ________________________________________________________________________________
Address_______________________________________________________________________________
Work Location _____________________________ N.C.S. Date____________________________
Line of Business ____________________________ Title __________________________________
Work Telephone # __________________________ Home Telephone # ______________________
Supervisor’s Name ___________________________ Supervisor’s # __________________________
Date of Occurrence ___________________________ Time/Shift _____________________________
Union Steward______________________________ Date Steward Received ___________________
Date Presented to Management_________________ Scheduled Time & Date ___________________
Following is a statement of what happened to me
(Use back of page or additional sheets if necessary): ______________________________________________________________
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FAX THIS COMPLETED FORM TO THE HALL at 410-335-0414 2/1/13
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Remedy Requested _______________________________________________________________________
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Members Signature__________________________________________ Date__________________________
FAX THIS COMPLETED FORM TO THE HALL at 410-335-0414