Report an Incident

Employer Information
Employer: Prince George's County Fire & EMS Department	Job Title:
Supervisor Name: Supervisor Phone:	Investigating Officer Name:: Investigating Officer Email:
Your Information
First Name: Last Name: Current Shift: Station Assignment: Phone: Personal Email: Are you an active member of IAFF 1619? Yes No Not Sure Are you a probationary employee? Yes No Not Sure
Disciplinary Record
In the past 3 years have you: Received a Step I? Yes No Not Sure Received a Step II? Yes No Not Sure Received a Step III? Yes No Not Sure
Are there any associated Criminal/MVA charges? Yes No Not Sure
What date were you given notice/investigatory interview form?
Did your supervisor inform you of your right to Union representation prior to any meetings or discussions? Yes No Not Sure
Date
Date Incident Occurred:
Statement of Issue
Type: -Select- Annual Leave AWOL Bereavement Leave Bid Auctions Change In Working Conditions Without Bargaining Collective Bargaining Agreement Violation Compensatory Leave Denial Of Union Representation Discipline - Alcohol/DUI Discipline - Attendance Discipline - Conduct Discipline - Drug Testing Discipline - Failure To Respond Discipline - Lost/Damaged Property Discipline - Other Discipline - Performance Discipline - Physicals Discipline - Probationary Firefighter Book Discipline - Vehicle Accident EEO Issue Failure To Provide Adequate Staffing FMLA Health & Safety Concern IOJ Mandatory Overtime Overtime Preference Payroll Issue - Certification Pay Payroll Issue - General Payroll Issue - Merit/COLA Raises Physicals Issue - General PPA Leave Award Promotions Retirement - DROP Retirement - DROP Extension Retirement - General Sick Leave Station Diesel Exhaust System Station Issue - HVAC Station Issue - Other
State the nature and the facts of the grievance: Who, what, when, where, why, and the names of witnesses or people you have already contacted, if any. Be sure to provide any mitigating factors.
Supporting Documents
Designation of Representation & Release of Information Authorization
I understand that with regard to the various administrative complaint processes IAFF Local 1619 and its representatives are functioning as personal representatives by mutual agreement. I, the undersigned, do hereby appoint and designate IAFF Local 1619 to represent me in connection with: a union grievance; any and all wrongs, complaints, grievances, disputes, controversies, or causes pertaining to my relationship with Prince George's County Fire & EMS Department as my employer. I, the undersigned, do authorize IAFF Local 1619 in their service to function as my personal representative by mutual agreement, to have access to relevant documents and records, and to speak to any employees or members of management on my behalf, and to hear any evidence or statements by anyone, that she/he deems necessary to my case. I understand that as the exclusive representative of the bargaining unit employees that the union will assign a representative to me and that my representative will be assigned by the President of IAFF Local 1619 or his/her designee. I certify that this request has been made freely, voluntarily, without coercion, and that the information given above is accurate and complete to the best of my knowledge.
Member Signature: Use your mouse, finger, or touch device to write your signature. Clear	Today's Date:
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