Va Form 10192 - Information For Pre-Complaint Processing - Department Of Veterans Affairs

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OMB Approved No. 2900-0716

Respondent Burden: 30 Minutes

Expiration Date: 12/31/2019

INFORMATION FOR PRE-COMPLAINT PROCESSING

I. REQUESTOR INFORMATION

1. NAME (Last, First, MI)

2. BEST CONTACT TELEPHONE NUMBER

3. MAILING ADDRESS (Street or P.O. Box, City, State, Zip + 4)

4. BUSINESS ADDRESS (Street, City, State, Zip + 4)

5. BUSINESS TELEPHONE NUMBER

6. BEST TIME TO CALL

7. E-MAIL ADDRESS

8. POSITION TITLE/GRADE

9. EMPLOYMENT STATUS (Check one)

10. SERVICE/SECTION/MAIL CODE

EMPLOYEE

APPLICANT

FORMER EMPLOYEE

OTHER

II. TYPE OF EMPLOYMENT/VA ORGANIZATION

1a.TYPE OF EMPLOYMENT

2. EMPLOYMENT

3. ORGANIZATION

4. BARGAINING UNIT EMPLOYE

FULL TIME

VHA

NCA

CANTEEN

TITLE 38

HYBRID 38

PART-TIME

VBA

OIT

OTHER

YES

TITLE 5

5. NAME OF FACILITY

6. FACILITY ADDRESS

7. FACILITY TELEPHONE NUMBER

III. SENIOR EXECUTIVE SERVICE (SES)

1. ARE YOU SES?

2. ARE YOU FILING AGAINST A SES?

YES

IV. DESCRIPTION OF ISSUE(S)/CLAIM(S)

1. USE THE SPACE BELOW TO BRIEFLY DESCRIBE THE ISSUE(S) OR ACTION(S) THAT PROMPTED YOU TO SEEK EEO COUNSELING AT THIS TIME.

On __________________________________, _______, __________

(Month)

(Day)

(Year)

V. DISCRIMINATION FACTORS (BASIS(ES))

Prohibited discrimination includes actions taken based on your Race, Color, Religion, Sex, Age (40 and over), National Origin, Physical and/or Mental Disability, Genetic

Information and/or Retaliation for participating in the EEO process or opposing unlawful discrimination. These categories are referred to on this form as basis(es).

1. WHAT BASIS(ES) OF DISCRIMINATION ARE YOU ALLEGING? (Please be specific, i.e., Race - African American, Sex - Female.)

VA FORM

10192

DEC 2016