FORM 10. Statement Concerning Discrimination Form 10 (p. 1) 

July 2020

UNITED STATES COURT OF APPEALS 

FOR THE FEDERAL CIRCUIT

FED. CIR. R. 15(c) STATEMENT CONCERNING DISCRIMINATION

Case Number:

Short Case Caption:

Name of Petitioner:

Purpose: This form is to help determine the proper forum for judicial review of a 

decision of the Merit Systems Protection Board (MSPB) or an Arbitrator, and in 

particular, those cases in which the federal employee has attributed the adverse 

employment action, in whole or in part, to bias based on race, color, religion, sex, age,

national origin, or handicapping condition, in violation of federal antidiscrimination 

laws. 

This court, while empowered to review MSPB and Arbitrator decisions dealing solely 

with civil-service claims, lacks authority to decide matters in which claims arising 

under federal discrimination laws have been asserted and not abandoned. Rather, 

the proper forum for judicial review of such matters is a federal district court. This 

form will assist the court in determining whether it needs to transfer a matter to a 

district court.

Instructions: Complete Section A. Complete Sections B and C only as directed by 

your answer to Section A. 

Section A

Before the MSPB or the Arbitrator, did you argue that the adverse employment 

action (1) was attributable to discrimination on the basis of race, color, religion, 

sex, age, national origin, or handicapping condition or (2) was retaliation for 

pursuing Equal Employment Opportunity activity? 

☐ Yes (complete Sections B and C) ☐ No (ignore Sections B and C)
FORM 10. Statement Concerning Discrimination Form 10 (p. 2) 

July 2020

Section B 

Complete this section only if you answered “Yes” to the question in Section A.

If you answered “No” to the question in Section A, skip this section.

1. Identify the discrimination claim(s) you raised before the MSPB or Arbitrator.

2. Have you filed a discrimination case in a United States district court from the

MSPB’s or Arbitrator’s decision?

☐ Yes ☐ No

If yes, please identify the case name(s) and number(s) and the status of the case(s) 

in the box below. 

3. Have you filed a discrimination case with the Equal Employment Opportunity

Commission from the MSPB’s or Arbitrator’s decision?

☐ Yes ☐ No

If yes, please identify the case name(s) and number(s) and the status of the case(s) 

in the box below. 
FORM 10. Statement Concerning Discrimination Form 10 (p. 3) 

July 2020

Section C 

Complete this section only if you answered “Yes” to the question in Section A. 

If you answered “No” to the question in Section A, skip this section. 

Check only one of the boxes below.

☐ Although I did claim that I was discriminated against before the MSPB or the

Arbitrator, I wish to abandon those discrimination claims and only pursue civilservice claims in the Federal Circuit rather than pursuing discrimination claims

and civil-service claims in district court. I understand that this means I will not

be able to raise the discrimination claims at any later point.

☐ I did claim that I was discriminated against before the MSPB or the Arbitrator

and I do not wish to abandon my discrimination claims.

CERTIFICATION

I certify the above information and any attached sheets (as necessary) are accurate 

and complete to the best of my knowledge.

Date: _________________ Signature:

Name: