City Employee Mediation Request

Name of person requesting mediation:

Labor Relations/Personnel Officer:

Name:

Department/Division:

Phone Number:

Use format xxx-xxx-xxxx

E-Mail Address:

Brief description of issue (s):

Information Requested

Employee's Name:

Available Days & Times to schedule a mediation session:

Pending vacations during the next month? If known or ADR will contact:

Department/Division If applicable:

Employee Job Title:

Employee Grade:

Employee E-mail Address:

Employee Phone Number:

Employee Salary:

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