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U.S. Department of Health and Human Services
Indian Health Manual

Part 7, Chapter 5: Manual Exhibit 7-5-A

Sample Grievance Format

DATE:

FROM:

SUBJECT:

To:  [Address a Stage 1 grievance to the first official within the Agency with Authority over the matter being grieved.  If you do not know who that official is, ask your immediate supervisor or consult with your Service Personnel Office.]

  1. This is a Stage__________________grievance under the Indian Health Service Administrative Grievance System.
  2. The matter(s) that aggrieve(s) me occurred on [give date(s)] and is described in detail as follows:  [Furnish sufficient detail to clearly identify the matter being grieved.  Fully explain the basis for your grievance and provide all available evidence, documentation, and rationale to support your grievance and the relief that you seek.]
  3. The personal relief I seek is:  [Specify clearly.  If it is already stated or implied above, restate it here].  [NOTE:  "Personal relief" means a specific remedy directly benefitting you.]

[Signature]

[Attachments:  (It is preferable to identify any attachments.)]

[NOTE:  It is preferable to make personal delivery when practicable.  When mailing is used, the postmark usually determines the date of the grievance.