University of North Carolina – General Administration

SPA Grievance Filing Form - Step 1 Mediation


Section I: Grievant Personnel Information
Grievant’s Full Name:
Division/Department: / Position Title:
Home Address: / Home Phone: / Work Phone:
Immediate Supervisor’s Title: / Email Address:
Section II: Type of Grievance
Grievable Issue(s) (Consult Section IV of the SPA Employee Grievance Policy for grievable issues): / Date of Action:
Did you discuss the grievable issue with your supervisor or other appropriate supervisor in your chain? You must have attempted to resolve the matter with your supervisor BEFORE you can file a grievance.
(please check one) Yes No
If yes, please provide the date of the discussion:
Section III: Description of Grievance
Brief statement of issues and facts on which grievance is based (attach additional sheet(s) if necessary):
Desired Relief or Resolution:
Section IV: Statement of Retaliation
Employees have the right to use this procedure free from threats or acts of retaliation, interference, coercion, restraint, discrimination, or reprisal. Employees may not be retaliated against for participating in a grievance as a grievant, a respondent, a witness, a support person, or as a grievance panel member.
Section V: Certification
I hereby certify that all information submitted on this Step 1 Filing form is true and complete to the best of my knowledge and belief. I understand that if I continue to be employed by the University during the resolution process of this grievance, I must continue to meet the performance and conduct expectations of my employment.
Grievant’s Signature / Date:
Section VI: Next Steps
The Grievance Coordinator will review your submission for eligibility. For Grievances in Regard to Disciplinary Action or Involuntary Separation due to Unavailability:
  • The Grievance Coordinator will schedule a Step 1 Mediation within 35 calendar days of the date you submitted your Step 1 Filing Form. Your department will designate a Respondent who will participate in the mediation with you. The Grievance Coordinator will inform you of the date, time, and location of the mediation.
  • If mediation does not resolve the issue, you have five (5) calendar days to submit the Step 2 Filing Form to the Grievance Coordinator to continue the grievance process.

Mail this form to: Human Resources, UNC General Administration, PO Box 2688, Chapel Hill, NC 27515
Hand Deliver form to: Human Resources, UNC General Administration, 910 Raleigh Road, Chapel Hill, NC 27514
Fax this form to: 919-843-2318
For Human Resources Use Only:
Received by: / Date:
Is this grievance timely: Yes No / Grievable Issue: Yes No

UNC GA Human Resources

Revised: 3/23/2015