Adverse Working Conditions Form Proposed Revision

Mt. Diablo Unified School District

Adverse Working Conditions Report Form

Each unit member may report, in writing, any adverse conditions in their working environment, including matters related to classroom temperature. Such report shall be filed within ten (10) working days of the time the unit member might reasonably have been expected to know of the adverse working condition which is the basis of the unit member's complaint.

Site Administrator or Supervisor Name*

First NameLast Name

Has your Office Manager submitted a work order or have you asked your Office Manager to submit a work order.*

YesNo

Please STOP

A work order must be submitted before filing an Adverse Working Conditions Form.

Does this Adverse Working Condition Report have to do with:*

Air ConditioningHeatingNone of the above

Site Administrator or Supervisor Email*

example@example.com

(MDEA unit member name)(Your Name)*

Your Email Address*

example@example.com

Site*

Room Number*

Was a work order submitted or did you request one be submitted?*

YesNo

The following condition(s) in my working environment need(s) to be corrected*

Signature*

Date*

Date

After submitting this form a copy of the form will be sent to: your site administrator or supervisor, Director of Maintenance and Operations, Chief Business Officer, Chief of Human Resources, and MDEA President.

Note to administrator/supervisor: A written response is due to the employee within ten (10) working days of the date this form is received. If the unsafe conditions are not corrected or a program leading to corrections is not agreed to by the unit member in writing, the unit member may appeal within five (5) working days of receipt of the district response, in writing, to the Chief of Human Resources, who shall issue a written response within five (5) working days after receipt. If the unit member is dissatisfied with the response issued by the Chief of Human Resources, the Association may, within five (5) working days of receipt of such a response, appeal the matter directly to binding arbitration pursuant to Article 3, Section 3.10.

M&O Response Status

M&O Response Remedy

M&O Response Date

Date