IX. MERIT SYSTEM PROTECTION BOARD (MSPB) AND NEGOTIATED GRIEVANCE
ON THE ISSUE(S) THAT PROMPTED YOU TO SEEK EEO COUNSELING, HAVE YOU:
1. FILED A UNION GRIEVANCE ON THE ISSUE?
IF YES, DATE
2. FILED AN MSPB APPEAL ON THIS ISSUE?
IF YES, DATE APPEAL FILED:
Include a copy of any written action(s) that caused you to seek counseling at this time.
XI. PRIVACY ACT STATEMENT
The collection of this information is authorized by the Equal Employment Opportunity Act of 1972, 42 U.S.C. § 2000e-16; the Age Discrimination in Employment
Act of 1967, as amended, 29 U.S.C. § 633a; the Rehabilitation Act of 1973, as amended, 29 U.S.C. § 794a; and Executive Order 11478, as amended. This
information will be used to adjudicate complaints of alleged discrimination and to evaluate the effectiveness of the EEO program.
I am aware that this form will be made part of the official informal complaint record and assigned an Office of Resolution Management (ORM) case number. If
the claim(s) contained herein are like or related to a formal complaint that is currently pending with ORM, prior to issuance of the Advisement of Rights letter, the
District Manager will determine if the claim(s) should be processed as an amendment to the pending formal complaint. You will be notified in writing.
You have a right to a representative during the EEO complaint process including during EEO counseling. You may select anyone to represent you, as long as their
positon with VA would not represent a conflict of interest. The EEO counselor cannot be your representative.
I DO NOT WANT A REPRESENTATIVE AT THIS TIME. I UNDERSTAND I MAY SELECT A REPRESENTATIVE LATER (or at any stage of the EEO process).
I HAVE A REPRESENTATIVE
2. NAME OF REPRESENTATIVE
3. EMAIL ADDRESS
6. TELEPHONE NUMBER
7. FAX NUMBER
XIV. ELECTION TO RECEIVE EEO CORRESPONDENCE VIA EMAIL
Signing the enclosed Election to Receive EEO Correspondence via Email will authorize the Office of Resolution Management (ORM) to send you all documents
XV. RESPONDENT BURDEN STATEMENT
In accordance with the Paperwork Reduction Act of 1995, The Department of Veterans Affairs (VA) may not conduct or sponsor, and the respondent is not
required to respond to this collection of information unless it displays a valid OMB Control Number. The valid OMB Control Number for this information
collection is 2900-0716. The collection of this information is voluntary. However, the information is necessary to determine if your complaint of employment
discrimination is acceptable for further processing in accordance with EEOC, 29 C.F.R. §1614. The time required to complete this information collection is
estimated to average 30 (minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing the form. Send comments regarding this burden estimate or any other aspects of this collection, including suggestions for reducing this
burden, to VA Clearance Officer (005R1B), 810 Vermont Avenue, Washington, DC 20420. SEND COMMENTS ONLY. DO NOT SEND THIS FORM, A
COMPLAINT OF EMPLOYMENT DISCRIMINATION, OR REQUEST FOR BENEFITS TO THIS ADDRESS.
PRINT YOUR NAME HERE
YOUR SIGNATURE (Ink signature)
PLEASE RETURN THIS FORM TO:
DEPARTMENT OF VETERANS AFFAIRS
OFFICE OF RESOLUTION MANAGEMENT (08)
ATTN: COUNSELOR TEAM LEADER
DISCLAIMER: Neither the Department of Veterans Affairs (VA) nor the Office of Resolution Management can guarantee the security of the content of external
emails (emails outside of the `va.gov' domain). Encryption offers protection against unintended readers accessing the content of e-mails. VA provides encryption
services to its employees for intra-agency e-mails and requires its use for email containing sensitive, personal information. Currently, VA does not offer encryption
for email accounts outside of the VA network. If you are concerned with the security of your email transmission, we suggest that you mail this form and any
attachments to the mailing address listed above.
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