The U.S. Equal Employment Opportunity Commission
This is a sample Intake Sheet from the U.S. Postal Service
1. Counselee:
Case No: | |
Tour: | Work Hours: |
Off Days: | Pay Loc: |
Duty Station: | Phone no: |
Complete only if changed | |
Home Address: | |
Phone: | Best times to call: |
If REDRESS is Declined, Reason:
Complete only if not explained on written complaint
2. Brief Description of Issues and Basis (es):
Complete if not listed on written complaint
3. Counselee's representative of choice and their status: (e.g., union steward, lawyer, friend)
Name and Position: | |
Duty Station/Address: | |
Telephone #: | Fax #: |
4. EEO Personnel has read or given the statement on the reverse side to the counselee:
YES | NO |
5. Counselee has been told the use of mediation is voluntary and he/she is not required to use mediation in order to resolve the dispute:
YES | NO |
6. Counselee has been advised that even though he/she has requested mediation, that request may be declined by the Postal Service:
YES | NO |
7. Counselee available dates for mediation:
8. Responsible Management Official:
Name and Position: | |
Duty Station/Address: | |
Telephone #: | Fax #: |
10. If the stated issued in item #2 include sexual harassment, follow REDRESS protocol with the District HR Manager to determine whether the complaint will be mediated.
Date protocol was completed and mediation request for sexual harassment issues was accepted: ______________________
11. Management Official available dates:
12. Person who will attend the mediation along with the Management Official, if any:
Name and Position: | |
Duty Station/Address: | |
Telephone #: | Fax #: |
13. Mediation Conference:
Location: |
Date/Time: |
Conference Room: |
Contact Person at Facility: |
14. Special needs or accommodations:
15. Mediation must be held no later than __________________ (90 Days from initial contact) in order not to violate legal timeliness.
16. Date the Counselee agreed to mediation: ______________ Date Scheduled: ___________
17. Mediation due: __________ (14 days) ___________ (21 days) ___________ (30 days)
18. Mediator Assigned: _____________________________ Type: ______________________
This page was last modified on April 17, 2002.