State of Wisconsin
Employment Relations Commission
2418 Crossroads Drive, Suite 1000, Madison, WI  53718-7896
Phone:  608-243-2424    Fax:  608-243-2433
Email:  werc@werc.state.wi.us	

REQUEST FOR IMPARTIAL HEARING OFFICER
	
INITIATING PARTY OR PARTIES:	THE FILING FEE FOR AN IMPARTIAL HEARING OFFICER IS $800 TO BE PAID CONSISTENT WITH THE EMPLOYER’S GRIEVANCE PROCEDURE. PROCESSING BEGINS WHEN A REQUEST AND THE APPLICABLE FILING FEE ARE RECEIVED BY THE COMMISSION.	
	Employee or Labor Organization		
	Employer		
	Joint		

All Information is Required

Parties are hereby advised that independent hearing officer decisions issued by the Commission Chairman or a staff attorney are published in their entirety on the WERC website to provide transparency to the public and as a resource for parties that may use the WERC’s services in future matters. In instances where confidential medical information is or may be referenced in the independent hearing officer decision, the parties should bring this to the Commission’s attention so that privacy may be respected as part of the publication process.
	
Name of Employee or Labor Organization	Name of Employer	
		
Street Address, City, State, Zip Code	Street Address, City, State, Zip Code	
		
Telephone No.	Email Address	Telephone No.	Email Address	
				
Name of Representative	Name of Representative	
		
Street Address, City, State, Zip Code (if different)	Street Address, City, State, Zip Code (if different)	
		
Telephone No.	Email Address	Telephone No.	Email Address	
				
Name of Representative 2	Name of Representative 2	
		
Street Address, City, State, Zip Code	Street Address, City, State, Zip Code	
		
Telephone No.	Email Address	Telephone No.	Email Address	
				
List and Describe the Issue(s) in Dispute	
	
 The initiating party requests that the Commission assigns a Commissioner or WERC Staff Member as an impartial hearing officer.	
 The parties jointly request the following Commissioner or WERC Staff Member as an impartial hearing officer (if available)		
Date Form Was Sent to the Commission and Unless Request Is Joint, to the Other Party		

I declare I have read the contents of this request and the statements are true and correct to the best of my knowledge.
	
Name		Title		
Signature		Date		
Name		Title		
Signature		Date