COMPLAINT OF DISCRIMINATION IN THE

FEDERAL GOVERNMENT

(This form is subject to the Privacy Act of 1974)

(See Page 3 for Privacy Act Statement and Instructions - Please type or print)

FOR AGENCY USE

1. FULL NAME OF COMPLAINANT (Last, First, Middle Initial) 2. TELEPHONE NUMBER (Include

 Area Code) 

3. ADDRESS (Street, City, State, and ZIP Code) a. HOME

 ( ) 

b. OFFICE

 ( ) 

4. FEDERAL OFFICE YOU BELIEVE DISCRIMINATED AGAINST YOU

 (Prepare a separate complaint form for each office which you believe

 discriminated against you.)

a. NAME OF OFFICE THAT YOU BELIEVE DISCRIMINATED AGAINST YOU

b. ADDRESS OF OFFICE (Street, City, State, and ZIP Code)

c. NAME AND TITLE OF PERSON(S) YOU BELIEVE DISCRIMINATED

 AGAINST YOU (If you know)

5. ARE YOU NOW WORKING FOR THE FEDERAL GOVERNMENT?

 (If answer is "Yes" complete a, b, and c below.)

YES NO

a. NAME OF AGENCY WHERE YOU WORK

b. ADDRESS OF YOUR AGENCY (Street, City, State, and ZIP Code)

c. TITLE AND GRADE OF YOUR JOB

6. ELECTION OF REPRESENTATION 7. DATE ON WHICH MOST RECENT

 ALLEGED DISCRIMINATION TOOK

 PLACE (YYYYMMDD)

8. CHECK BELOW WHY YOU BELIEVE YOU WERE DISCRIMINATED AGAINST

a. RACE (If so, state your race) 

b. COLOR (If so, state your color) 

c. RELIGION (If so, state your religion) 

d. NATIONAL ORIGIN (If so, state your national origin) 

e. SEX (If so, state your sex) 

f. AGE (If so, state your age) (See Note 1) 

g. DISABILITY (If so, state whether mental or physical) 

h. SEXUAL HARASSMENT (If so, state your sex and the sex of the person you believe harassed you) 

9. EXPLAIN IN SPECIFICS HOW YOU BELIEVE YOU WERE DISCRIMINATED AGAINST (treated differently from other employees or applicants)

 DUE TO YOUR RACE, COLOR, RELIGION, NATIONAL ORIGIN, SEX, AGE, PREGNANCY, GENETIC INFORMATION, DISABILITY, OR REPRISAL

 (For each allegation, please state to the best of your knowledge, information and belief what incident occurred and when the incident occurred. 

 If you need more space, continue on another sheet of paper.)

Note 1: Complaints of discrimination because of age apply only to employees or applicants who were at least 40 years of age at the time the 

 discriminatory action is alleged to have occurred.

ATTORNEY NON-ATTORNEY NO REPRESENTATION

a. NAME OF REPRESENTATIVE (If applicable)

b. ADDRESS (Include ZIP Code)

c. TELEPHONE NUMBER (Incl. area code) d. FAX NUMBER (Incl. area code) e. E-MAIL ADDRESS

i. REPRISAL FOR PREVIOUS EEO ACTIVITY (If so, when) 

j. GENETIC INFORMATION
10. I HAVE DISCUSSED MY COMPLAINT WITH AN EQUAL EMPLOYMENT

 OPPORTUNITY COUNSELOR (See instructions)

YES NO

11. NAME OF COUNSELOR (If applicable)

13. WHAT RELIEF ARE YOU SEEKING TO RESOLVE THIS COMPLAINT? (State specific corrective action desired for each allegation.)

15. SIGNATURE OF COMPLAINANT 16. DATE OF THIS COMPLAINT

 (YYYYMMDD)

12. HAVE THE ISSUES IDENTIFIED IN BLOCK 9 BEEN APPEALED TO THE MERIT SYSTEMS PROTECTION BOARD (MSPB) OR FILED UNDER

 A UNION NEGOTIATED GRIEVANCE PROCEDURE? NO YES (If Yes, complete 12.a., b., and c. below)

 a. (X one)

MSPB UNION NEGOTIATED GRIEVANCE

b. DATE FILED (YYYYMMDD) c. MSPB OR UNION DOCKET NUMBER (If known)

14. LIST NAME(S) OF WITNESS(ES) AND BRIEFLY STATE WHAT INFORMATION WITNESS MAY CONTRIBUTE TO THE INVESTIGATION OF

 YOUR COMPLAINT. 
PRIVACY ACT STATEMENT

READ INSTRUCTIONS CAREFULLY

This form should be used only if you, as an applicant for Federal employment or a Federal employee, think you have been discriminated against

due to race, color, religion, sex, national origin, age, pregnancy, genetic information, disability, or reprisal by a Federal agency and have

presented the matter for informal resolution to an Equal Employment Opportunity Counselor within 45 calendar days of the date the incident

occurred or, if a personnel action, within 45 calendar days of its effective date.

Your complaint must be filed within 15 calendar days of the date of your final interview with the Equal Employment Opportunity Counselor. If

the matter has not been resolved to your satisfaction within 30 calendar days of your first interview with the Equal Employment Opportunity

Counselor and the final counseling interview has not been completed within that time, you have the right to file a complaint at any time

thereafter up to 15 days after the final interview.

These time limits may be extended if you show that you were not notified of the time limits and were not otherwise aware of them, or that you

were prevented by circumstances beyond your control from submitting the matter within the time limits, or for other reasons considered

sufficient by the agency.

If you need help in the preparation of your complaint, you may contact the Equal Employment Opportunity Counselor who provided you with

your initial counseling, or you may secure help from a representative of your choice.

You may have a representative of your own choosing at all stages of the processing of your complaints.

You will have an opportunity to talk with an investigator and present all the facts which you believe show discrimination. The investigator will

not be under the jurisdiction of the head of that part of the agency in which the alleged discrimination took place.

After the investigation of your complaint has been completed, you will be furnished a copy of the Report of Investigation. You will be given an

opportunity to request a hearing, which will be conducted by an Administrative Judge assigned by the Equal Employment Opportunity

Commission (EEOC). The hearing will be held at a convenient time and place. At the hearing, you may present witnesses and other evidence

on your behalf.

The final decision (in writing) will be made by the head of the agency or his or her designee. If a hearing is held on your complaint, the head of

the agency or the designee will review the decision recommended by the Administrative Judge before making a final decision, and will furnish

you with a transcript of the hearing, a copy of the findings, analysis, and recommended action of the Administrative Judge, along with the

agency's final decision letter.

If you are not satisfied with the final agency decision, you have the right to appeal that decision within 30 calendar days after receipt to the Equal

Employment Opportunity Commission, Office of Federal Operations, P.O. Box 77960, Washington, DC 20013.

If your complaint is based on race, color, religion, sex, national origin, pregnancy, genetic information, disability, or reprisal, you may file a civil

action in an appropriate U.S. District Court within 90 days of receipt of the agency's decision or, if you elect to file an appeal with the

Commission, you may still file a civil action in a Federal District Court within 90 days of the Commission's decision if you are dissatisfied with

the decision.

If your complaint is based on race, color, religion, sex, national origin, pregnancy, genetic information, disability, or reprisal, you may file a civil

action in an appropriate U.S. District Court if you have not received a final agency decision within 180 days of filing your complaint with the

agency or if you have not received a final Commission decision within 180 days of filing your appeal with the Commission's Office of Federal

Operations.