Dd Form 2655 - Complaint Of Discrimination In The Federal Government Page 2

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10. I HAVE DISCUSSED MY COMPLAINT WITH AN EQUAL EMPLOYMENT
11. NAME OF COUNSELOR (If applicable)
OPPORTUNITY COUNSELOR (See instructions)
YES
NO
12. HAVE THE ISSUES IDENTIFIED IN BLOCK 9 BEEN APPEALED TO THE MERIT SYSTEMS PROTECTION BOARD (MSPB) OR FILED UNDER
A UNION NEGOTIATED GRIEVANCE PROCEDURE?
NO
YES (If Yes, complete 12.a., b., and c. below)
a. (X one)
b. DATE FILED (YYYYMMDD)
c. MSPB OR UNION DOCKET NUMBER (If known)
MSPB
UNION NEGOTIATED GRIEVANCE
13. WHAT RELIEF ARE YOU SEEKING TO RESOLVE THIS COMPLAINT? (State specific corrective action desired for each allegation.)
14. LIST NAME(S) OF WITNESS(ES) AND BRIEFLY STATE WHAT INFORMATION WITNESS MAY CONTRIBUTE TO THE INVESTIGATION OF
YOUR COMPLAINT.
15. SIGNATURE OF COMPLAINANT
16. DATE OF THIS COMPLAINT
(YYYYMMDD)
DD FORM 2655, JUN 2012
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