Va Form 10192 - Information For Pre-Complaint Processing - Department Of Veterans Affairs Page 3

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IX. MERIT SYSTEM PROTECTION BOARD (MSPB) AND NEGOTIATED GRIEVANCE

ON THE ISSUE(S) THAT PROMPTED YOU TO SEEK EEO COUNSELING, HAVE YOU:

YES

1. FILED A UNION GRIEVANCE ON THE ISSUE?

IF YES, DATE

CURRENT STEP:

2. FILED AN MSPB APPEAL ON THIS ISSUE?

YES

IF YES, DATE APPEAL FILED:

X. DOCUMENTATION

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.

XII. AUTHORIZATION

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.

XIII. REPRESENTATION

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

4. ATTORNEY

YES

5. ADDRESSS

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

electronically.

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)

DATE SIGNED

PLEASE RETURN THIS FORM TO:

DEPARTMENT OF VETERANS AFFAIRS

OFFICE OF RESOLUTION MANAGEMENT (08)

ATTN: COUNSELOR TEAM LEADER

EMAIL ADDRESS:

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.

VA FORM

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10192

DEC 2016