PPSM 70
Exhibit A
1/3/11
1 of 2
Employee Complaint Form
Complainant name ____________________________________ Phone __________________________
Department __________________________________________ Job title _________________________
Send correspondence to (address) _______________________________________________________
___________________________________________________________________________________
Supervisor name _____________________________________ Phone __________________________
If Represented:
Representative name __________________________________ Phone __________________________
Organization _________________________________________________________________________
Non-UC mailing address _______________________________________________________________
Scope of Complaint:
A complaint is defined as:
1) A claim by an individual employee regarding a specific management act which is alleged to have
adversely affected the employee’s existing terms or conditions of employment; or
2) A claim by an individual employee (adversely affected by a management action) alleging that a
provision of Personnel Policies for Staff Members (PPSM) has been violated.
Describe your complaint in detail, including the following five points. Attach additional sheets if needed.
1. Management act to be reviewed.
2. Date or dates of each act.
3. University policy or procedure violated (if any).
4. How did the management act violate policy or procedure?
5. How were you adversely affected?