Formal Complaint Of Discrimination In The Federal Government
Download a blank fillable Formal Complaint Of Discrimination In The Federal Government in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Formal Complaint Of Discrimination In The Federal Government with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3Clear Form
Print Form
FORMAL COMPLAINT OF DISCRIMINATION IN THE FEDERAL GOVERNMENT
PRIVACY ACT STATEMENT
AUTHORITY: 42 U.S.C. 2000e-16(b) and (c); 29 U.S.C. 204(f) and 206(d); 29 U.S.C. 633(a); 29 U.S.C. 791; Reorg. Plan No. 1 of 1978, 43 FR 19607
(May 9, 1978); E.O. 12106, 44 FR 1053 (January 3, 1979).
PRINCIPAL PURPOSE(S): Information is collected in order to counsel, investigate and adjudicate complaints of employment discrimination and related
appeals brought by applicants and current and former federal employees against federal employers.
ROUTINE USE(S): To disclose information to another federal agency, to a court, or to a party in litigation before a court or in an administrative
proceeding being conducted by a federal agency when the government is a party to the judicial or administrative proceeding. To provide information to a
congressional office from the record of an individual in response to an inquiry from that congressional office made at the request of that individual. To
disclose to an authorized appeal grievance examiner, formal complaints examiner, administrative judge, equal employment opportunity investigator,
arbitrator or other duly authorized official engaged in investigation or settlement of a grievance, complaint or appeal filed by an employee. To disclose, in
response to a request for discovery or for appearance of a witness, information that is relevant to the subject matter involved in a pending judicial or
administrative proceeding. For a complete list of routine uses, visit
DISCLOSURE: Voluntary; however, failure to complete all portions of this form may lead to dismissal of complaint on the basis of inadequate data on
which to determine if complaint is acceptable for processing.
RULES OF USE: Rules for collecting, using, retaining, and safeguarding this information are contained in Privacy Act System Notice EEOC/Govt-1,
entitled “Equal Employment Opportunity in the Federal Government Complaint and Appeal Records” available at
govwide/eeoc_govt-1.html.
1. NAME OF COMPLAINANT (Last, first, middle initial)
2. I.D. Number (EEO Office use only)
3. DLA CASE Number (EEO Office use only)
5. HOME ADDRESS (Include city, state, and ZIP Code)
4a. HOME TELEPHONE NUMBER
4b. WORK TELEPHONE NUMBER
6. DO YOU HAVE A REPRESENTATIVE?
a. YES (Complete Item 6c)
b. NO
c. IF YES, PROVIDE NAME, ADDRESS, AND TELEPHONE NUMBER OF
7. NAME OF AGENCY AND ADDRESS WHERE ALLEGATIONS AROSE
REPRESENTATIVE (Include city, state, and ZIP Code)
(Include city, state, and ZIP Code)
THIS REPRESENTATIVE IS
IS NOT
AN ATTORNEY.
10. ARE YOU A FEDERAL EMPLOYEE OR APPLICANT?
9. DATE OF MOST RECENT ACT
8. NAME AND LOCATION OF AGENCY ORGANIZATION
WHERE YOU WORK
OF ALLEGED DISCRIMINATION
(MM/DD/YY)
a. EMPLOYEE, GRADE, SERIES, TITLE:
b. FORMER FEDERAL EMPLOYEE, GRADE, SERIES, TITLE:
c. APPLICANT FOR EMPLOYMENT
11. REASON YOU BELIEVE YOU WERE DISCRIMINATED AGAINST ("X" below) Complete only those items below that are applicable to your complaint.
a. RACE (State your race)
e. DISABILITY (Describe nature of your disability)
PHYSICAL
MENTAL
b. COLOR (State your color)
g. SEX
f. AGE (State your date of birth)
c. RELIGION (State your religion)
MALE
FEMALE
h. REPRISAL (Date and nature of your participation in the processing of an EEO complaint or other EEO related
activity)
d. NATIONAL ORIGIN (State your National Origin)
12. I HAVE DISCUSSED MY COMPLAINT WITH
12c. IF "YES," NAME AND TELEPHONE
13. DATE RECEIVED NOTICE
12d. DATE YOU FIRST ASKED
AN EEO COUNSELOR (See last page)
NUMBER OF COUNSELOR
OF RIGHT TO FILE
TO SEE EEO COUNSELOR
a. YES (Complete 12c)
b. NO
DLA FORM 1808, FEB 2006
PREVIOUS EDITION IS OBSOLETE.
PDF (DLA)
Page 1 of 3
ADVERTISEMENT
0 votes
Related Articles
Related forms
Eligibility Complaint Of Discrimination Under The Provisions Of The California Fair Employment And Housing Act Template- California Department Of Fair Employment And Housing
Legal
Form Ct-23 Schedule B - Shipments Of Unstamped Cigarettes Made To Agencies Of The Federal Government Or Connecticut State Government
Financial
Form Ct-23 - Schedule B - Shipments Of Unstamped Cigarettes Made To Agencies Of The Federal Government Or Connecticut State Government
Financial
Form R-1304 - Sales Tax Exemption Certificate For Certain Purchases And Leases For The Federal Government Or The U.s. Department Of Navy - 2007
Financial
Form Rmft-7- Schedule B - Gasoline Products Sold To The Federal Government, To Foreign Governments, To Municipal Corporations Owning And Operating Local Transportation Systems, To Certain Privately Owned Public Utilities, Or For Aviation Purposes - Illino
Financial
Related Categories
Parent category: Legal