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Department of Transportation
Individual Complaint Of Employment Discrimination Form DOT F 1050-8
Form Instructions and Privacy Statement
GENERAL: This form should be used only if you, as an applicant for employment with the Department of Transportation, or as a present or former Department of Transportation employee: 1) believe you have been discriminated against because of your race, color, religion, sex, national origin, age (40 years or older at the time of the event giving rise to your claim), physical or mental disability, sexual orientation, genetic information or believe that you have been retaliated against for participating in activities by civil rights statutes. (Sexual orientation complaints filed against the Department are processed in accordance with the Secretary of Transportation’s Equal Employment Opportunity (EEO) Policy Statement dated May 7, 1993 and Executive Order 13087 issued May 28, 1998. Complaints based on sexual orientation are not covered by the Equal Employment Opportunity Commission regulations that govern the processing of Federal Sector discrimination complaints (Title 29 Code of Federal Regulations (C.F.R.), Part 1614.), and 2) have presented the matter for informal resolution to an EEO Counselor within 45 days of the event giving rise to your claim, or within 45 days of first becoming aware of the alleged discrimination. IMPORTANT NOTE: In certain situations, the information provided in Part III of the attached complaint form may be used in lieu of an affidavit in the investigation of your complaint. Accordingly, the information you provide in this part should be brief, clear, and complete. WHEN TO FILE: In accordance with 29 C.F.R. § 1614.106, your formal complaint must be filed within 15 calendar days of the date you received the Notice of Right to File a Discrimination Complaint form from your EEO Counselor. You must sign and date your complaint. If you are represented by an attorney, the attorney may sign the complaint on your behalf. These time limits may be extended: 1) if you show that you were not notified of the time limits and were not otherwise aware of them, or 2) if you were prevented by circumstances beyond your control from submitting the matter within the time limits, or 3) for other reasons considered sufficient by the Department. REPRESENTATION: You may have a representative of your own choosing at all stages of the processing of your complaint. However, your representative will be disqualified if such representation would conflict with the official or collateral duties of the representative. No EEO Counselor or EEO Officer may serve as a representative. (Your representative need not be an attorney, but only an attorney representative may sign the complaint on your behalf.) WHERE TO FILE: The complaint should be filed with the Associate Director, Compliance Operations Division (S-34), Departmental Office of Civil Rights, 1200 New Jersey Avenue, S.E., 76-401, Washington, DC 20590. Filing instructions are contained in the “Right to File” form which was provided by your EEO Counselor. Keep a copy of the completed complaint form for your records. ----------------------------------------------------------- PRIVACY ACT STATEMENT 1. FORM NUMBER/TITLE DATE: Department of Transportation Form Number _____________, Individual Complaint of Employment Discrimination with the Department of Transportation. 2. AUTHORITY: 42 U.S.C. 2000e; 29 U.S.C. 633a; PL 95-062 as amended; 5 U.S.C. 1303 and 1304; 5 C.F.R. 5.2 and 5.3; 29 C.F.R. 1614.105 and 1614.107; and Executive Order 11478, as amended. 3. PRINCIPAL PURPOSES: The purpose of this complaint form, whether recorded initially on the form or taken from a letter from the Complainant, is to record the filing of a formal written complaint of employment discrimination with the Department of Transportation on the grounds of race, color, religion, sex, national origin, age, physical or mental disability, sexual orientation, genetic information or retaliation, and to reach a decision on the complaint. Information provided on this form will be used by the Department of Transportation to determine whether the complaint was timely filed and whether the claims in the complaint are within the purview of 29 C.F.R. Part 1614, and to provide a factual basis for investigation of the complaint. 4. ROUTINE USES: Other disclosures may be: a. to respond to a request from a Member of Congress regarding the status of the complaint or appeal; b. to respond to a court subpoena and/or to refer to a district court in connection with a civil suit; c. to disclose information to authorized officials or personnel to adjudicate a complaint or appeal; d. to disclose information to another Federal agency or to a court or third party in litigation when the Government is party to a suit before the court. 5. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY, AND EFFECT ON INDIVIDUAL BY NOT PROVIDING INFORMATION: Formal complaints of employment discrimination must be in writing, signed by the Complainant (or attorney representative), and must identify the parties and action or policy at issue. Failure to comply may result in the Department of Transportation dismissing the complaint. It is not mandatory that this form be used to provide the requested information.
