FOR AGENCY USE
COMPLAINT OF DISCRIMINATION IN THE
FEDERAL GOVERNMENT
(This form is subject to the Privacy Act of 1974)
(See Page 3 for Privacy Act Statement and Iinstructions - Please type or print)
1. FULL NAME OF COMPLAINANT (Last, First, Middle Initial)
2. TELEPHONE NUMBER (Include
Area Code)
3. ADDRESS (Street, City, State, and ZIP Code)
a. HOME
(
)
b. OFFICE
(
)
4. FEDERAL OFFICE YOU BELIEVE DISCRIMINATED AGAINST YOU
5. ARE YOU NOW WORKING FOR THE FEDERAL GOVERNMENT?
(Prepare a separate complaint form for each office which you believe
(If answer is "Yes" complete a, b, and c below.)
discriminated against you.)
YES
NO
a. NAME OF OFFICE THAT YOU BELIEVE DISCRIMINATED AGAINST YOU
a. NAME OF AGENCY WHERE YOU WORK
b. ADDRESS OF OFFICE (Street, City, State, and ZIP Code)
b. ADDRESS OF YOUR AGENCY (Street, City, State, and ZIP Code)
c. NAME AND TITLE OF PERSON(S) YOU BELIEVE DISCRIMINATED
c. TITLE AND GRADE OF YOUR JOB
AGAINST YOU (If you know)
6. ELECTION OF REPRESENTATION
7. DATE ON WHICH MOST RECENT
ATTORNEY
NON-ATTORNEY
NO REPRESENTATION
ALLEGED DISCRIMINATION TOOK
a. NAME OF REPRESENTATIVE (If applicable)
PLACE (YYYYMMDD)
b. ADDRESS (Include ZIP Code)
c. TELEPHONE NUMBER (Incl. area code)
d. FAX NUMBER (Incl. area code)
e. E-MAIL ADDRESS
8. CHECK BELOW WHY YOU BELIEVE YOU WERE DISCRIMINATED AGAINST
a. RACE (If so, state your race)
b. COLOR (If so, state your color)
c. RELIGION (If so, state your religion)
d. NATIONAL ORIGIN (If so, state your national origin)
e. SEX (If so, state your sex)
f. AGE (If so, state your age) (See Note 1)
g. DISABILITY (If so, state whether mental or physical)
h. SEXUAL HARASSMENT (If so, state your sex and the sex of the person you believe harassed you)
i. REPRISAL FOR PREVIOUS EEO ACTIVITY (If so, when)
j. GENETIC INFORMATION
k. PREGNANCY
Note 1: Complaints of discrimination because of age apply only to employees or applicants who were at least 40 years of age at the time the
discriminatory action is alleged to have occurred.
9. EXPLAIN IN SPECIFICS HOW YOU BELIEVE YOU WERE DISCRIMINATED AGAINST (treated differently from other employees or applicants)
DUE TO YOUR RACE, COLOR, RELIGION, NATIONAL ORIGIN, SEX, AGE, PREGNANCY, GENETIC INFORMATION, DISABILITY, OR REPRISAL
(For each allegation, please state to the best of your knowledge, information and belief what incident occurred and when the incident occurred.
If you need more space, continue on another sheet of paper.)
DD FORM 2655, JUN 2012
PREVIOUS EDITION IS OBSOLETE.
Page 1 of 3 Pages
Adobe Professional 8.0