Va Form 10192 - Information For Pre-Complaint Processing - Department Of Veterans Affairs Page 2
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3FOR RETALIATION ALLEGATIONS ONLY:
2. 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.
a. On __________________________________, _______, __________, I engaged in EEO activity. Case No: __________________________________
(Month)
(Day)
(Year)
b. On __________________________________, _______, __________, I engaged in EEO activity. Case No: __________________________________
(Month)
(Day)
(Year)
VI. COMPARISONS
1. FOR EACH ITEM LISTED IN SECTION IV AND V, PROVIDE WHO YOU BELIEVE YOU WERE TREATED DIFFERENTLY THAN AND WHY.
a. __________________________________________________________
______________________________________________________________________________
(Name of Employee)
(Basis(es) that describe the employee, i.e., sex (male), National Origin (hispanic))
was treated differently than I when:
b. __________________________________________________________
______________________________________________________________________________
(Name of Employee)
(Basis(es) that describe the employee, i.e., sex (male), National Origin (hispanic))
was treated differently than I when:
VII. RESPONSIBLE MANAGEMENT OFFICIAL(S) (RMO)
List the name(s) of the Responsible Management official(s) who took the action(s) which prompted you to seek counseling at this time.
1a. NAME (Last, First, MI)
1b. TITLE
1c. OFFICE
1d. GRADE LEVEL
2a. NAME (Last, First, MI)
2b. TITLE
2c. OFFICE
2d. GRADE LEVEL
3a. NAME (Last, First, MI)
3b. TITLE
3c. OFFICE
3d. GRADE LEVEL
Retaliation Allegations Only:
4. WAS/WERE THE RESPONSIBLE MANAGEMENT OFFICIAL(S) LISTED ABOVE AWARE OF YOUR PRIOR EEO ACTIVITY?
YES (If YES, explain how the official(s) became aware)
NO
VIII. RESOLUTION
1. WHAT ARE YOU SEEKING AS A RESOLUTION TO YOUR PRE-COMPLAINT?
VA FORM
Page 2 of 3
10192
DEC 2016
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