Member Intake Form "*" indicates required fields What type of support are you requesting?*Please select support typeIssue/ComplaintUnion Sponsored BenefitsHardship AssistanceHiddenSection Break – Show for all choicesMember InformationFirst Name* Last Name* Street Address* Zip Code* Shift* Cell Phone* Department* Classification* Facility InformationFacility Name* Date of Hire* Facility Street Address* Facility Zip Code Are you an HCSG employee?* Yes No HiddenSection Break – Show for Issue/ComplaintWhat happened?What happened?*Describe your question or incidents which gave rise to your issue.Who was involved?*Give names and titles (include witnesses).When did it occur?*Give date and time.Why do you believe that this is a grievance?*What is management violating: contract, rules and regulations, unfair treatment, existing policy, past practice; local, state, federal laws, etc?What would be the remedy?*What must management do to correct the problem?Additional commentsThis is not an official grievance form, a Union Organizer will follow up with you to review the issue listed aboveHiddenSection Break – Hardship or Benefits questions onlyPlease type your question below*An organizer will follow up with you within the next 48 hoursEmailThis field is for validation purposes and should be left unchanged.