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REV. 3/98 |
Complaint of Discrimination |
| 1. Complainant's Name: ______________________________ | Place of Employment: ________________________________ |
| Street Address: ______________________________________ | Address: ______________________________________________ |
| City, State, Zip Code: _______________________________ | City, State, Zip Code: _________________________________ |
| Home Phone: ________________________________________ | Work Phone: __________________________________________ |
| 2. DOI Office which you believe discriminated against you? | |
| Bureau: _________________________________________________ | Division/Office: _______________________________________ |
| Address: ________________________________________________ | Region ________________________________________________ |
| City/State: ______________________________________________ | |
| 3. Basis(es)
for believing you were discriminated against? (Check one or more, and provide
the specific
Information.) |
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| _______ Race _________________________ | _______ Age (Date of Birth) __________________ |
| _______ Color _________________________ | _______ Physical Handicap __________________ |
| _______ Religion _________________________ | _______ Mental Handicap __________________ |
| _______ Sex _________________________ | _______ Reprisal __________________ |
| _______ National Origin _______________ | (Date of previous EEO activity)________________ |
| 4. Allegation(s)
of discrimination? (For each allegation, state the date and the specific
incident causing you to believe that you have been discriminated against.
FOR EXAMPLE: I was discriminated against on January 1, 1992, when I was
not selected for the position of Analyst. (Use additional pages as necessary.)
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| 5. Have you discussed your complaint with an EEO Counselor? Yes _______ No _______ (If yes, name of Counselor): | |
| _____________________________________ Date you first contacted the Counselor:______________________________________ | |
| 6. Are you agreeable to using the Alternative Dispute Resolution (ADR) process? Yes _______ No _______ | |
| 7. Have you
presented these allegations to any other forum? If so, please indicate:
_______Negotiated Grievance Procedure ______ Merit Systems Protection Board ______ Court (Civil Action) |
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| 8. List the
remedies which you believe will resolve your complaint: (Use additional
pages, as necessary.)
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| 9. Complainant's
Signature: Date:
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| 10. For Agency
Use:
Complaint Docket Number: Date Received of Postmarked: |
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READ CAREFULLY!
You may use this form to file a complaint. This form should be used if you, as an applicant for Department of the Interior (DOI) employment or as a DOI employee, believe you have been discriminated against because of race, color, religion, sex, national origin, age, handicap, or reprisal by the DOI. When filing a complaint, you should provide a statement of what occurred, when the incident(s) occurred, and why you believe you were treated in a discriminatory manner. Your complaint must bear an original signature.
COMPLAINTS PROCESSING INFORMATION
*Prior to filing a complaint, you must present the matter(s) that you believe are discriminatory to an EEO Counselor for informal resolution, within 45 calendar days from the date the incident occurred, or 45 calendar days from the effective date of a personnel action. The EEO Counselor has 30 calendar days to attempt a resolution of the matter, and conduct a final interview with you. The EEO Counselor will notify you in writing of your right to file a complaint. You have 15 calendar days to file your complaint after receipt of the Notice of Final Interview. The 15-day filing period may be waived if you show that you were not notified of the time limits for filing, or that you were prevented from meeting the time limits by circumstances beyond your control. Failure to file your complaint within the 15-calendar day period may result in the dismissal of your complaint.
*Your written complaint should be filed by you or your designated representative with the Bureau Equal Opportunity Officer where the alleged discriminatory incident occurred, the Secretary of the Interior, or with the Director, Office for Equal Opportunity, U. S. Department of the Interior, 1849 C Street, N. W., MS-5221, Washington, D. C. 20240. If you choose to have a representative, you must designate the representative in writing, providing their full name and address.
*If your complaint is accepted for processing, the investigation should be completed within 180 calendar days from the filing date of your complaint. By written agreement, you and the agency may voluntarily extend the time period for no more than an additional 90 calendar days. The DOI will provide you with a copy of the Report of Investigation (ROI). Should the DOI fail to issue the ROI within 180 days of the filing date of your complaint, you may request a hearing.
Upon receipt of the investigative record, you will have 30 calendar days to request a hearing before an Administrative Judge (AJ) of the Equal Employment Opportunity Commission (EEOC), or to request an immediate final decision from the DOI.
*If you choose a hearing, the EEOC Administrative Judge will issue a Statement of Findings and Conclusions, within 180 days of their receipt of your hearing request, unless the AJ extends the time period for good cause. If you do not request either a hearing or a final decision within the 30-calendar day time period, the DOI will issue a final decision.
*The DOI will issue a final decision within 60 calendar days from receipt of your request for a final decision. If the Administrative Judge issues a Statement of Findings and Conclusions, the DOI has 60 calendar days to reject, modify or accept the Judge's findings and conclusions. If the DOI has not issued a final decision within 60 calendar days, the findings and conclusions of the Administrative Judge will become the DOI's final decision. If you are dissatisfied with the agency's final decision, or the dismissal of all, or a portion of your complaint, you may appeal the decision within 30 calendar days of your receipt of the decision, to the EEOC, Office of Federal Operations, P.O. Box 19848, Washingtron, D.C. 20036.
*In lieu of an appeal to the EEOC, you may file a civil action in an appropriate U. S. District Court, within 90 calendar days of your receipt of the final decision. Also, you may file a civil action after 180 calendar days has elapsed from the filing date of your complaint, if the agency has not issued a final decision and no appeal has been filed.
*If you file an appeal with the EEOC and you are not satisfied with the EEOC's decision, you may file a civil action within 90 calendar days of your receipt of the EEOC's final decision. You may also file a civil action after 180 calendar days has elapsed from the filing date of your appeal, if the EEOC has not issued a final decision.
*If you file a civil action involving this complaint, you must specifically name the Secretary of the Interior, as defendant. Failure to do so may result in the loss of any judicial redress to which you may be entitled. Additionally, the filing of a civil action will terminate the agency's processing of your complaint, or the EEOC's processing of your appeal.
*There are special provisions in the regulations with respect to related processes, such as mixed case complaints, negotiated grievance procedures, class complaints, etc. For further information you may wish to consult Title 29 of the Code of Federal Regulations (CFR), Part 1614.
PRIVACY ACT STATEMENT
THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974.
AUTHORITY: 42 USC 2000E-16
PRINCIPAL PURPOSE: To establish the case records and to assist in the processing of the complaint.
ROUTINE USE: Used by EEO officials, Administrative Judges, investigators, and/or representatives of the EEOC and the Department of Justice in relation to the processing of complaints and appeals.
DISCLOSURE IF VOLUNTARY: Failure to furnish the information requested on the form may delay or impairt the processing of the complaint.