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

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

Sample Decision Format

FROM:

SUBJECT:  Your Stage____ Grievance [indicate stage 1 or 2]

TO:

  1. I received your Stage____________ grievance on___________________ [date].
  2. My decision is:  [State the decision and include a report of findings and the reasons for the decision as required by Section 4(B)(2) and Section 5(D).]
  3. NOTES:
    1. If you have no authority over the matter(s) grieved, state that you have forwarded the grievance to the appropriate official (give name and address).
    2. If the decision is to reject or cancel the grievance, comply with Section 6(K) or Section 6(L) as applicable.
    3. If the decision is to grant the personal relief sought, be specific in describing it to avoid future disputes as to its meaning or implementation.
    4. If the decision is to not grant the personal relief sought, include a report of findings and reasons for your decision on the matter(s) grieved.
    5. If this is a Stage 1 decision, state how the employee may pursue the matter(s) at the next level.

[Signature]

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