Ngb Form 5437 - Request For Military Equal Opportunity Complaint Facilitation

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REQUEST FOR MILITARY EQUAL OPPORTUNITY COMPLAINT FACILITATION
The proponent of this form is NG-J1-EO, the prescribing directive is CNGBI 9600.01
Privacy Act Statement
42 U.S.C. Section 2000d
AUTHORITY:
PRINCIPLE PURPOSE
To document the request for facilitation of a military equal opportunity complaint of discrimination in the Army National Guard
or the Air National Guard
ROUTINE USES: None
Voluntary. However, failure to complete all portions of this form could affect the timely processing of the facilitation request or result
DISCLOSURE:
in the rejection of the facilitation request.
Section I - Complaint Information
* To be completed by the SEEM and submitted with the Agreement to Facilitate
1. Date of request
4. Local docket number
5. Preferred method of mediation
Formal Complaint
Informal Complaint
On Site
VTC
6. Date of complainant's initial contact with EEO office
7. Basis
Race
Color
National Origin
Religion
Gender
8. Claims/Issues
Section II - Party Requesting Facilitation
9. Name
10. Job Title and grade or rank
11. Phone number
12. Address
13. Email
14. Activity/Major Command information
15. Complainant's activity and installation
16. Name of complainant's representative (if applicable)
Section III - Party against Whom complaint is filed
17. Name
18. Job Title and grade or rank
19. Major Command against (if different from complainant's Major Command)
Section IV - EEO POC Contact Information (SEEM)
20. Name
21. a) Phone
b) Fax
22. Address
c) Email:
23. Preferences
24.
Parties have been told that the use of alternate dispute resolution is voluntary and that they
YES
NO
are not required to participate in order to resolve the dispute:
25.
Do the parties have any objection to the use of co-facilitators?
YES
NO
Section V - Scheduling
25. Location of the facilitation session
(address, room number)
27. Three dates when parties agree to make themselves available for facilitation
a) First choice
b) Second choice
c) Third choice
NGB Form 5437, 20130621

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