Formal Complaint Of Discrimination In The Federal Government Page 2

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FORMAL COMPLAINT OF DISCRIMINATION IN THE FEDERAL GOVERNMENT

14. TELL BRIEFLY HOW YOU WERE DISCRIMINATED AGAINST. INCLUDE THE DATE OF EACH ALLEGED DISCRIMINATORY INCIDENT. (That is, tell how you

were treated differently from other employees or applicants because of your race, color, religion, sex, national origin, age, mental or physical disability or reprisal.)

(If your complaint involves more than one allegation of discrimination, list and number each such allegation separately. Tell what happened, who was involved and when

it happened. (Use additional sheets, if necessary.)

15. WHAT SPECIFIC CORRECTIVE ACTION DO YOU WANT TAKEN ON YOUR COMPLAINT? (If more than one claim is being made, state overall corrective action desired

and the specific corrective action desired for each separate claim.

17. SIGNATURE OF COMPLAINANT

16. HAVE ANY OF THE INCIDENTS LISTED IN ITEM 14 BEEN APPEALED TO THE

U.S. MERIT SYSTEMS PROTECTION BOARD (MSPB) OR FILED UNDER A

NEGOTIATED GRIEVANCE PROCEDURE?

a. YES. Explain. (Include date and MSPB Docket No.)

b. NO

18. DATE COMPLAINT SIGNED BY

19. DATE COMPLAINT FILED

COMPLAINANT (MM/DD/YY)

(EEO OFFICE USE ONLY)

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