Form R-19 Arbitrator's Report and Fee Statement

FEDERAL MEDIATION AND CONCILIATION SERVICE
FMCS Form R-19
Revised March 2022
Fax: (202) 606-3749

Form Approved
OMB No. 3076-0003
Expires XX-XX-XXXX

ARBITRATOR’S REPORT AND FEE STATEMENT

FMCS Case # ____________________ ARBITRATOR __________________________DATE OF AWARD_________

I. EMPLOYER ____________________________ II. UNION

____________________________________

(Please check either a or b, and complete c and d)

III. ISSUES

a. ____ New or reopened contract terms

b. ____ Contract interpretation or application

c. Was arbitrability of grievance involved? ____ Yes ____ No

□ Procedural

(If YES, check one or both)

□ Substantive

d. Issue or Issues (Please check only one issue per grievance)
1. ____ Affirmative Action
18. ____ Management Rights
2. ____ Absenteeism
19. ____ Official Time
3. ____ Arbitrability
20. ____ Past Practices
4. ____ Bargaining Unit Work
21. ____ Pension and Welfare Plans
5. ____ Conduct (Off-Duty/Personal)
22 ____ Pension Claim (Federal Statute)
6. ____ Demotion
23. ____ Promotion
7. ____ Discipline (Non-Discharge)
24. ____ Retirement
8. ____ Discipline (Discharge)
25. ____ Safety/Health Conditions
9. ____ Discrimination (Any type)
26. ____ Seniority
10. ____ Fringe Benefits
27. ____ Sexual Harassment
11. ____ Grievance Mediation
28. ____ Strikes/Lockouts, Work
12. ____ Health/Hospitalization
Stoppages/Slowdowns
13. ____ Hiring Practice
29. ____ Subcontracting/Contracting Out
14. ____ Job Performance
30. ____ Tenure/Reappointment
15. ____ Job Posting/Bidding
31. ____ Wages (Overtime, Holiday pay, etc.)
16. ____ Jurisdictional Dispute
32. ____ Work Hours/Schedules/Assignments
17. ____ Layoffs/Bumping/Recall
33. ____ Working Conditions/Work Orders
34. ____ Violence or Threats
IV. HEARING
a. Were briefs filed? ___YES ___NO If YES, give date ________ b. Was transcript taken ___YES
___NO
c. No. of Grievances heard: ________ d. Date of hearing: ____________ e. Date of grievance: ____________
f. Extension granted by either party on initial award date? ___YES ___NO
V. FEES AND DAYS FOR SERVICES AS AN ARBITRATOR:
# OF DAYS:_________ + __________+ __________= ___________ X
Hearings

Travel

Study

Total

$ _____________ = $ _________
Per Diem Rate

EXPENSES: Transportation: $___________________ + Other: $_______________=

Total Fee

$_________________________

Total Expenses
Amt. Payable by Company:

$____________________

Amt. Payable by Union:

$ ________________

VII. Cancellation Fee Only: __________

VI. Panel: If tripartite panel or more than one arbitrator made the award, check here: _____
VIII. DATE of this Report: ________________________ Signature: ____________________________________
Privacy Act Statement. 29 U.S.C. § 172, et seq., authorize the FMCS to collect this information. The primary use of the information is to allow FMCS officials to
maintain a roster of arbitrators. Additional disclosures of the information may be made: (1) to a Federal, State, or local law enforcement agency if FMCS becomes
aware of a violation or potential violation of law or regulation; (2) to a court or party in a court or Federal administrative proceeding if the Government is a party or in
order to comply with a judge-issued subpoena; (3) to the National Archives and Records Administration or the General Services Administration in record
management inspections; (4) to the Office of Management and Budget during legislative coordination on private relief legislation; (5) in a judicial or administrative
proceeding if the information is relevant to the subject matter; (6) to provide arbitrator information to parties seeking arbitration services; and (7) information
collected may be used by FMCS to provide information concerning FMCS trainings, events, presentations, conferences, and other educational opportunities and
programs. This information is voluntary and will not be disclosed unless authorized by law. Failure to provide the requested information could result in delays in
processing arbitrator applications, rejection of arbitrator applications, suspension, or removal.