Required regardless of employment status
Agency Employed By
Preferred Method of Communication?
1. Direct Appeal
a. Appeal Action
[See CSR 19-20 A. 1 or 20-20 A.1 for DSD] Check only those that apply.
Suspension or temporary reduction in pay
Whistleblower violation* (Complete e, f, & g below.)
Involuntary demotion with an attendant loss of pay
b. Date of Agency Action
c. Action checked above involved discrimination or harassment based on
Gender Identity and Expression
Other protected status under federal, state and/or local law
Pregnancy or Related Condition
d. Action checked above involved retaliation based on [protected activity under CSR 16-22]
Identify Agency retaliatory action or threat of retaliatory action
e. Identify the official misconduct you reported
f. When and to whom did you report the official misconduct?
g. What was the adverse employment action or threat of adverse action taken by Agency and when did it occur?
2. Appeal of Complaint or Grievance [CSR 19-20 B or 20-20 B for DSD]. Attach complaint, grievance and Agency's response.
a. Grievance resulting in violation of
[Section of CSR, Charter, or ordinance]
Identify Agency action that violated above rule(s):
b. Describe how Agency action affected your pay, benefits or status
[§19-20 B.3 or 20-20 B.3 for DSD]
c. Grievance of “Unacceptable" performance review [§19-20 B.1 or 20-20 B.1 for DSD]
d. Date of my complaint or grievance:
e. Date of Agency response:
3. Reason For Appeal
4. Remedy Sought
Are you interested in mediating this appeal?
Representative Information (
All fields required if there is a Representative)
Rep First Name
Rep Last Name
Rep Street Address
Rep City, ST
Rep Bar Registration Number
When you press "Submit" below, your Appeal will be sent to the Career Service Hearing Office. If you do not receive a response within 3 business days, please contact us at 720-913-5703.