Steward Assessment Tool
This assessment tool has been successfully used in collecting input from members who are in conflict with
management or non-MAPE employees. This form should be kept confidential and shared only with regional
leads, chief stewards, stewards and business agents. Please be thorough and complete in your documentation.
This assessment may be used as evidence to document what is occurring and lead to a preliminary decision by
union representatives of what, if any, type of violation the work environment is creating. Please attach any
additional documentation provided by the member(s) and provide a copy to your regional lead.
 Name of Steward:
 Agency:
 Date of Assessment:
IDENTIFICATION OF COMPLAINANT(S):
During your initial meeting, you may not be writing down names or information if your member(s) is fearful
and needs to build trust. However, following the meeting, document as much information as possible.
 Do the behaviors violate the Respectful Workplace Policy?
☐ yes
☐ no
 Are the behaviors bullying (targeted, repeated, health-harming)?
☐ yes
☐ no
 Is it a member complaint about an isolated action/decision by a manager/supervisor that does not violate
the policy?
☐ yes ☐ no
 Is the complainant an (individual, group, department or work site)? (Circle one.)
Please list complainant names here:
 Name and job title of the perpetrator:
 How long have the behaviors been going on?
☐
☐
☐
☐
0-3 months
4-6 months
7-12 months
More than 1 year
 List names of witnesses:
 Are co-workers aware of the behaviors?
☐ yes
☐ no
 Have the behaviors been reported to anyone?
☐ yes
☐ no
 Have any employees resigned because of the behaviors?
☐ yes
☐ no
Describe the behaviors: (Use adjectives to describe types of behaviors and nature of complaints shared by
the member(s). Include where the situations have occurred and their frequency.)
How is the behavior impacting the member’s ability to do their assigned work?
Is/Are the member(s) experiencing medical and/or mental health issues resulting from
their mistreatment? (Has a medical provider provided documentation? Is there FMLA paperwork being
processed or is it completed? Has the employee requested an ADA accommodation?) Examples include high blood
pressure, depression, anxiety, high stress levels, etc. See Guidebook for more examples.
Is the member interested in contacting the EAP for help with this situation?
☐ yes ☐ no
Please provide the member with the phone number for the State’s Employee Assistance Program - 651259-3840 or 1-800-657-3719. A LifeMatters EAP consultant is available any day at any time.
The member may also visit the LifeMatters web site at: www.mylifematters.com (password: stmn1)