Local 6360
Statement of Occurrence

Name:  ________________________________Title:  ___________________________NCS:  ___/___/___
Home Address:  ______________________________________________________________________ 
Work Phone:  ___________________ Home Phone:  __________________ Cell:  ___________________
Work Location:  ____________________________________Floor/ Dept.:  _________________________
Manager Name:  ____________________________________ Mgr Phone:  __________________
The following is a statement of what happened to me on____/____/____.
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I herby give consent to the inspection of any records kept by the employer, which may affect the conditions of my employment, by any authorized union representative. This authorization is given in accordance with the existing agreement between union and the employer.
						             Signed______________________________

Steward:  __________________________________  Date:  ___/___/___  Grievance Number: ____________________

Grievance Occurred:  ___/___/___ @________________________________________________________
			    Date					Location

Continued from Page 1.

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If needed attach additional pages to back.
This section to be filled out by your Union Representative.
Union’s Statement of what happened:
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Specific Basis of Grievance or Article(s) of contract involved:
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Company’s Position:
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Proposed Settlement:
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Local 6360

Release of Personal and/or Medical Records

I, _________________________, the undersigned, do hereby grant permission for all Union Representatives involved to examine, review, and obtain copies when necessary, of any and all portions of my personal and/or medical records maintained by the Company, which are necessary to process a grievance on my behalf.

I understand all information and discussions of a personal nature pertaining to these records or copies of same will be held in strict confidence unless otherwise stated by me.

SIGNED:  _______________________	DATE:  ________________

Local 6360
Request for Information

Grievant Name: 

To whom it may Concern,

As the exclusive collective bargaining representative responsible for the processing of the grievance captioned above, we request that you provide the following information for our use in the processing of this case. This information is absolutely essential to an intelligent handling of the case by the Union, and any refusal to provide the information will substantially impair the Unions ability to resolve this grievance. 

The specific information you are requested to produce is stated below, and you are requested to produce such information within (5) days: 

1.

2.

3.

4.

5.

Name:	_____________________________		Date:  __________________