Intake Form All fields are mandatory. Enter ‘N/A’ for irrelevant fields. Fill Out Intake FormFull Name *Job Title *Where Do You Work? *Please include HHS Operating DivisionWork Address *City *State/Province *ZIP / Postal Code *Work Phone *Work Email *Supervisor Name/Title: *Home Address *City *State/Province *ZIP / Postal Code *Home or Cell Phone *Personal Email *Bargaining Unit StatusBargaining Unit Status *Active Dues Paying MemberNot a Dues Paying MemberDo Not Know/UnsureCode in Box 37 on your SF-50 *Please refer to the “Deductions” tab on your Leave & Earnings Statement (LES) for code H4W4 to identify dues paymentCollective Bargaining Agreement (CBA) ViolationPlease reference current Collective Bargaining Agreement (CBA) effective date July 2023. CBA can be found on the HHS intranet by searching the name: HHS-NTEU 2023 National Agreement or using the link https://intranet.hhs.gov/document/hhs-nteu-2023-national-agreementArea *Article *Section *Explanation of What You Have Identified As a CBA Violation *Issue(s) or Concern(s)Date of Incident *Time of Incident *HoursMinutesAMPMLocation of Incident *Please provide a brief explanation of your issue(s)/concern(s) *Is there any evidence or supporting documentation besides your statements and recollections? *YesNoType of Supporting Document(s) *EmailPMAPWritten ReprimandDenail Of RequestOtherNoneSupporting Document *Drag and Drop (or) Choose FilesPlease Attach All Supporting DocumentationHow have all or any of these events harmed you? *Have you already discussed this with anyone in management? *YesNoWhat did they say? *Disciplinary ActionDisciplinary action taken if any at the time of completing Intake form *Verbal WarningWritten WarningSuspensionFinal WrittenTerminationLeave RestrictionPerformance Improvement Plan (PIP)OtherPlease check all that applyRequested RemedyWhat do you want to see happen as a possible resolution? Please be specific. *Employee Signature *Your browser does not support e-Signature field.Date Signed *Send Message Become a MemberJoin NTEU Chapter 229 and be part of a community dedicated to supporting federal employees.Join Now
