PD 14 Submission

PD 14 Submission

Section 1: Agency Information

Date Submitted

Agency/University*

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Submitted By*

Agency Representative E-mail*

Agency Representative Phone Number

E-mail address(es) for additional agency notifications

* If sending alerts to multiple recipients, please separate the e-mail addresses with a semi-colon (;)*

Section 2: Employee Information

Employee First Name*

Employee Last Name*

Personnel Number*

Race

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Gender

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Position Classification

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Competency Level

*For State University Employees Only*

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Section 3: Case Information

Case Number

*Enter OAH Case Number if applicable.*

Type of Settlement*

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Grievable Issue*

*Select all that apply.*

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Discrimination Basis

*Only applicable if grievance is based on discrimination. Select all that apply.*

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Primary Corrective Action

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Secondary Corrective Action

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Additional Corrective Actions

Summary of Facts

Section 4: Pay Calculations

All fields must be completed. Enter 0 if there is no amount.

Total Gross Earnings*

List the grand total payment due to the employee here. Calculate earnings of the employee by each month listing the number of work days to be paid and the total amount of payment for the month. Back pay shall include any across the board compensation that would have been included in the employee’s regular salary, including one time “bonuses”, eligible longevity pay, and all holidays that the grievant would have been paid for not including any holiday premium pay. Total Other pay includes longevity shift premiums and leave.

Total Interim Income*

This gross pay amount shall be reduced by any interim income and/or unemployment compensation received by the employee during the specified period. Earnings derived from approved secondary employment which the employee received prior to and/or during the specified period will not be deducted from the gross earnings amount. Any unemployment insurance benefits paid to the employee shall also be deducted from the gross back pay amount.

Other Deductions*

Attorney Fees*

25 NCAC 01J .1319 SITUATIONS IN WHICH ATTORNEY'S FEES MAY BE AWARDED

Attorney's fees may be awarded only in the following situations:

(1) the grievant is reinstated;

(2) the grievant is awarded back pay from either a demotion or a dismissal, without regard to whether the grievant has been reinstated; or

(3) the grievant prevails in a whistleblower grievance.

Front Pay*

Punitive Damages*

Other*

Section 5: Certification Information

Checking these boxes certifies that the appropriate agency has reviewed and approved the settlement agreement.

The PD-14 has been reviewed and approved by the Office of State Controller, if needed.*

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The settlement has been reviewed and approved by the State Health Plan.*

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Section 6: Document Uploads

A copy of the notarized PD-14, decision, agreement, order or any other supporting documentation must be attached to this form.

File Upload*

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