Brotherhood
of Maintenance of Way Employes
Initial Questionnaire / Information Form
Claims or Grievances
*Time limits start on the
date of the occurrence (violation)*
Note: This form is for
internal union use only. It is not to be submitted to the company.
This form should be submitted to your union representative as soon as possible. The success of your claim or grievance depends upon the information you give.
Claimant
Name_______________________________________________________
SS#: _____________________ Employee #: ___________________________
Phone #’s: ( ) ___________________ ( ) ____________________
Address: ____________________________________________________________
Position
____________________ Gang # _______ Headquarters _____________
Seniority Date:
______________________Assigned Hours (Reg)
_____________
(Position) (Date)
________________________________________ Work Week: __________________________
(Position) (Date)
__________________________________
Date Furloughed: (If Appl.)________
(Position) (Date)
What did
the company do that is a violation of the rules and/or agreement?
__________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________
WHEN
Date (s)
of violation: _________________________________________________
Time: (From) _____________ (To)
____________ Total Hrs. Involved _______
Is this
a continuing claim? (Yes) _______ (No) ______ Please check one.
Note: This is a
two-page form. Continue on the next page.
WHERE
did the violation occur?
Location (MP): __________ Station: ________________ District: __________
Division: ________________
Town: _________________ State:
_____________
WHY is this a claim or grievance?
_________________________________________________________________________________________________________________________________________________________________________________________________________.
(Position/
(Name) (SS & Emp #) (Sen. Date) ( Assignment)
(Phone #)
_________________ ___________ __________ ___________ ( ) ________
_________________ ___________ __________ ___________ ( ) ________
_________________ ___________ __________ ___________ ( ) ________
_________________ ___________ __________ ___________ ( ) ________
_________________ ___________ __________ ___________ ( ) ________
(Position/
(Name) (SS & Emp #) (Sen. Date) ( Assignment)
(Phone #)
_________________ ___________ __________ ___________ ( ) ________
_________________ ___________ __________ ___________ ( ) ________
_________________ ___________ __________ ___________ ( ) ________
Signed: ________________________________ Date: ________________
(Claimant’s Signature)
Filed by: _______________________________
(Representative’s Name)
Note: The information contained in this form will be used to develop a written claim or grievance. Due to strict enforcement of the time limits provided in your agreement for filing a claim or grievance, you should submit it to your Union representative as soon as possible. If additional space is necessary or if additional documentation and/or information is available, please make attachments.