I. REQUIRED ELEMENTS A. AGGRIEVED PERSON Name: Job Title/Series/Grade:________________________________________________ Place of Employment:__________________________________________________ Work Phone No:______________ Home Phone No:________________________ Home Address: ______________________________________________________ ________________________________________________________ ________________________________________________________ B. CHRONOLOGY OF EEO COUNSELING Date of Initial Contact: Date of Initial Interview:______________________________________________ Date of Alleged Discriminatory Event:___________________________________ 45th Day After Event:_________________________________________________ Reason for delayed contact beyond 45 days, if applicable: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Date Counseling Report Requested:_____________________________________ Date Counseling Report Submitted:_____________________________________ C. BASIS(ES) FOR ALLEGED DISCRIMINATION 1) [ ] Race (Specify)_______________________________________ 2) [ ] Color (Specify)______________________________________ 3) [ ] National Origin (Specify)______________________________ 4) [ ] Sex (Specify)________________________________________ 5) [ ] Age (Date of Birth)___________________________________ 6) [ ] Mental Disability (Specify)____________________________ 7) [ ] Physical Disability (Specify)___________________________ 8) [ ] Religion (Specify)____________________________________ 9) [ ] Reprisal (Identify earlier event and/or opposed practice, give date)__________________________________ D. PRECISE DESCRIPTION OF THE ISSUE(S) COUNSELED E. REMEDY REQUESTED F. EEO COUNSELOR'S CHECKLIST - THE COUNSELOR ADVISED THE AGGRIEVED PERSON IN WRITING OF THE RIGHTS AND RESPONSIBILITIES CONTAINED IN THE EEO COUNSELOR CHECKLIST. II. SUMMARY OF INFORMAL RESOLUTION ATTEMPTS A. IF THE COUNSELOR ATTEMPTED RESOLUTION 1. Personal Contacts 2. Documents Reviewed 3. Summary of Informal Resolution Attempt B. IF AGGRIEVED OPTED FOR ADR, COUNSELOR'S STATEMENT THAT THE ADR PROCESS WAS FULLY EXPLAINED TO THE AGGRIEVED INDIVIDUAL/SUMMARY OF INFORMATION GIVEN TO THE AGGRIEVED INDIVIDUAL AND THE AGENCY BY THE COUNSELOR _____________________________ __________________________ Name of EEO Counselor Telephone Number _____________________________ ___________________________ Signature of Counselor Office Address _____________________________ Date
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