Individual Complaint Of Employment Discrimination Page 4
Download a blank fillable Individual Complaint Of Employment Discrimination 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 Individual Complaint Of Employment Discrimination 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
3
4Part III Alleged Discriminatory Actions
13. Name and Address of Treasury Bureau that took the
14. If your complaint involves nonselection for a position,
action at issue (if different than item 5.)
please complete the following:
Bureau
Office and Organizational Component
Position Title
Series
Grade
Street Address
/
/
Vacancy Announcement Number
Date Learned of Nonselection
State
Zip Code
City
(A) Describe the action taken against you that you believe was discriminatory; (B) Give the date when the action occurred,
15.
and the name of each person responsible for the action; (C) Describe how you were treated differently than other
employees or applicants because of your race, color, religion, sex, national origin, age, disability, or in retaliation for your
participation in the EEO process or opposition to alleged discriminatory practices; (D) Indicate what harm, if any, came to
you in your work situation as a result of this action. (You may but are not required to attach extra sheets.) (E) If the basis
of your complaint is your parental status, sexual orientation, or protected genetic information, use this form, but your
complaint is not statutorily based and will follow a separate, parallel process.
16. Mark below ONLY the bases you believe were relied on to take the actions described in #15.
Physical or Mental Disability (Describe)
Age (Date of Birth)
Race (State Race)
Retaliation/Reprisal (Dates of Prior EEO Activity)
Color (State Color)
/
/
Religion (State Religion)
Sexual Orientation
Sex (Specify)
Parental Status
National Origin (Specify)
Protected Genetic Information
17. What remedial or corrective action are you seeking to resolve this matter?
18. If you wish to amend your complaint (or provide additional evidence), indicate the complaint case number
of that complaint.
Part IV Contact
EEO Counseling is not required if you are amending an existing open complaint.
Complete items 19, 20, and 24 even if you did not contact a counselor.
19. When did the most recent discriminatory event occur?
23. When did you receive your "Notice of Right to File"?
/
/
/
/
Month
Day
Month
Day
Year
Year
20. When did you first become aware of the alleged
24. On this same matter, have you filed a grievance or
discrimination?
appeal under:
/
/
Month
Day
Year
Negotiated grievance procedure
No
YES
21. When did you contact an EEO counselor?
Agency grievance procedure
YES
No
/
/
MSPB appeal procedure
YES
No
Month
Day
Year
If you filed a grievance or appeal, provide date filed, case
22. Did you discuss all actions raised in item 15 with an
number, and present status.
EEO counselor?
YES
NO
(If no, explain on attached sheet)
23. Name and telephone number of EEO counselor.
Telephone No.
Name
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal