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Attachm ent A Grievance Form (For use only of ICs participating in the Peer Resolution Panel pilot: (CC, NHLBI, NIA, NIAID, NINDS, OD) Stage 1: I am filing this Grievance Form with CCR/HR to request a pre-hearing conference with my supervisor (or the most app ropriate m anageme nt official), ___ _____ _____ _____ _____ _____ _, within 14 c alendar d ays. I recogniz e that if we do not reach a mutual agreement a higher level management official will be called to participate with us in the prehearing conference at this stage. I am grieving because (please describe): _________________________________________________________________________________________________ _________________________________________________________________________________________________ __________________________________________________________________________________ The date the event occurred: _________________________________ (Note to g rievant: Th is form mu st be filed with in 14 calen dar day s of the even t or your b ecomin g awar e of the eve nt.) I am requesting the following solution (must direc tly benefit the g rievant) : _________________________________________________________________________________________________ _______________________________________________________________________________________ Signature of Grievant and date: Print name: _______________________________________________________________ _______________________________________________________________ Name and phone number of representative (if any): ___________________________________________________ Grievant’s NIH address and phone number: ______________________________________________________ ______________________________________________________ ______________________________________________________ At the conclusion of the Stage 1 period, the grievant must select and initial one of the below: _________ This matter has been resolved per separate signed agreement (attached); or _________ This matter was not resolved and I do not wish to pursue it; or _________ This matter was not reso lved, and I w ish to proce ed with the pe er resolution panel at Stag e 2 of this grievance process . (Continu e with the se ction belo w.) Stage 2 I wish to proc eed with the p eer resolutio n panel to d ecide my gr ievance. I rec ognize the p anel will be pro vided with this grievance form describing the basis of my grievance and the solution I am requesting. The signed brief management response (in the space below or attached separately) addresses the event that was the basis of my grievance: ____________________________________________ ___________________ Signature of Stage 1 Management Official/Manager Date