Please print and fill out.

1. Problem/Issue Statement (1-2 sentences): Describe specific events (behavior) that show what is happening and how, to whom, when, and where.

2. Briefly describe why this is an issue, for whom, when, where, and how.

3. Describe attempts to resolve problem/issue: Include names, titles, timeframes, etc.

4. What is the change that is desired? What is happening that you want stopped, or what would you like to happen that is not and why?

5. Why is it in your labor or management counterparts' best interest to support resolution of this issue?

6. Briefly describe as many options as possible for resolving/addressing the problem/issue stated. (Be creative!)

Option 1:

Option 2:

Option 3:

Submitted by:

Title:

Worksite:

Worksite phone:

Representing (check one): ___ CSEA ___Management

Date submitted: