Ps Form 2564-A - Information For Pre-Complaint Counseling
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1
2
3Certified Mail No.
Date Mail
or
Hand Delivered On
U.S. Postal Service
Information for Pre-Complaint Counseling
By (Initials)
Case No.
On _________________________________, you requested an appointment with a Dispute Resolution Specialist.
Month, Day, Year
Important: Please Read. You should complete this form and return it to the EEO office within 10 calendar days of receipt . This the only
notification that you will receive regarding the necessity for you to complete this form.
A. Requester Information
Name (Last, First, MI)
Home Telephone No.
Social Security No.
(
)
Your Mailing Address
Name of Postal Facility Where You Work
Office Telephone No.
(
)
Address of Postal Facility
Email Address *
Employment Status (Check One)
Position Title
Grade Level
Applicant
Casual
TE
Career
Pay Location
Tour
Duty Hours
Off Days (If Tour I, Show Nights Off)
Time in Current Position
____ Years
____ Months
Your Supervisor’s Name
Supervisor’s Title
Supervisor’s Telephone No.
(
)
* Providing this information will authorize the U.S. Postal Service to send you important documents electronically.
B. Discrimination Factors
Prohibited discrimination includes actions taken based on your Race, Color, Religion, Sex, Age (40+), National Origin, Physical and/or Mental
Disability, or in Retaliation (actions based on your participation in prior EEO activity). These categories are referred to on this form as factors.
What Factor(s) of Discrimination Are You Alleging? (Please be specific, i.e., Race - African American, Sex - Female.)
For Retaliation Allegations Only: If you are alleging retaliation discrimination, provide the date(s) and specifics of the EEO activity which you feel
caused you to be retaliated against.
1. On ___________________________, I engaged in EEO activity.
Case No.: __________________________.
Month, Day, Year
2. On ___________________________, I engaged in EEO activity.
Case No.: __________________________.
Month, Day, Year
C. Description of Incident/Activity
Please use the space below to briefly describe the incident or action that prompted you to seek EEO counseling at this time.
On _____________________________________, 20____,
Month, Day
Year
2564-A,
PS Form
March 2001 (Page 1 of 3)
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