If you believe that you have been discriminated against at work because of your race, color, religion, sex including pregnancy, gender identity, and sexual orientation, national origin, age 40 or older, disability or genetic information, you can file a charge of discrimination. Remember, a charge of employment discrimination must be filed within the time limits imposed by law, generally within 180 days or in some places 300 days of the alleged discrimination. In addition to your signed complaint form, you may attachupload up to 4 supporting documents that relate to the allegations of discrimination described in your complaint form. I have discussed my complaint with an equal employment opportunity counselor see instructions yes no 11. You have a right to file a formal complaint at any time thereafter, up to 15 calendar days after you have received your notice of right to file. An employee complaint form allows an employee to document and submit a grievance concerning inappropriate or illegal misconduct witnessed in the workplace. The structure of such complaint forms make for a formalized and clear framework of facts, and employers and human resource personnel utilizing these forms are presented with a systematic process for interpreting the issue at hand. Sample notice of right to file a formal complaint after. Written complaint formal stage step 2 file formal complaint eoasl will assist you in preparing ngb form 3331 filed within 30 days of incident. Employee complaint forms should be made available to all employees.
Read the instructions on the reverse side of this form carefully before completing the front of this form. The basics of the federal employee eeo complaint process. This sample document is an example only and should be adapted to your organizations needs. Complaint was filed by community legal services, inc. The roi will contain your formal complaint, the eeo counselors report, the abovedescribed acceptance letter and affidavits, and other supporting documents from management and you. Your notice of right to file contains the address where your formal complaint must be mailed or delivered.
Call or visit any ofccp district and area office if you have questions about the complaint process, want to discuss your complaint, or. Eeo complaint frequently asked questions national archives. Equal employment opportunity forms federal communications. Accepted claims are assigned thereafter to an eeo investigator for the purpose of conducting an appropriate investigation. A letter with the necessary complaint information will be sufficient to file a complaint. Eeo will notify you of the right to either request a hearing before an eeoc administrative judge aj. Ps form 2565, eeo complaint of discrimination in the. Once you file a formal complaint, it is assigned to an investigator, often a contractor, who will put together a report of investigation. Since that date, i have received no further communication from your office.
Your formal complaint must be in writing and must be signed and dated by you or your attorney. This form can be used by a tenant to file a complaint with the landowner. State specific corrective action desired for each allegation. In the first 1050 pages of the roi, the investigator will summarize the report and testimony.
You may obtain a formal discrimination complaint form from your eeo counselor or from the. For purposes of this form, a station employment unit is a station or a group of commonly owned stations in the same market that share at least one employee. The notice will explain how and where to file your formal eeo complaint. Feb 20, 2017 the roi will contain your formal complaint, the eeo counselors report, the abovedescribed acceptance letter and affidavits, and other supporting documents from management and you. I have therefore sought timely counseling but no eeo counselor has contacted me. The bookmarks must be named in a manner that describes what the document is for example, eeo counselors report, formal complaint, exhibit a 2014 performance evaluation, etc. Charge of discrimination declaration of the charging party letter brief in support of the charge of discrimination documents supporting the charge. A detailed look at the federal eeo complaint process.
The eeo forms are attached below for viewing and download. Please return completed form to the broward county professional standardshuman rights section. After your complaint is filed, the agency will send you a letter letting you know it. The role of the eeo counselor, including that the counselor is not an advocate for either the aggrieved person or the agency and acts. The pre complaint, formal andor class complaint process.
To attach your complaint form, click on the browse button. Equal employment opportunity discrimination complaints. Enter your first and last name, email address, phone number, and any comments in the designated boxes below. Indicate by marking in the appropriate box the type of reporting unit for which this copy of the form is submitted mark only one box. A charge of discrimination is a signed statement asserting that. Eeo formal complaint process civil rights division nrcs.
Be careful to use the form that fits your case and the type of pleading you want to file. Thirty days have passed and this is a formal complaint of discrimination. After filing a formal complaint, a ny new incidents can be added as amendment to your existing complaint. If this does not work, feel free to file a complaint to the equal employment opportunity commission using eeoc complaint form pdf within 15 days.
Please immediately complete the entire form and return it to the u. Filing a formal eeo discrimination complaint in federal. In the first 1050 pages of the roi, the investigator will summarize the. Understanding the possible scope of relief in a discrimination complaint is critical to both the eeo counselor and investigator. Module 3 complaints investigations reference notebook. Eeoc charge form, eeoc hearing request form, mspb appeal form, ofo appeal. Eeo counselor will assist you in preparing ngb form 75r to file with seem. This form is to be used to file a formal complaint of discrimination if you. The precomplaint, formal andor class complaint process. We encourage you to consult with an attorney licensed in your state before using these materials.
Equal employment opportunity internal complaint process. Module 3 complaints investigations reference notebook for. Eeo formal complaint process civil rights division. Sample eeoc complaint with cover letter and memo o. You are entitled to a representative of your choice at all stages of the eeo complaint process. The complaint must be sufficiently precise to describe the actions or practices, which form the basis of the complaint. Prepare a separate complaint form for each office which you believe discriminated. Eeo 21, forms for eeoc charge, eeoc hearing, mspb appeal. Please return completed form to office of intergovernmental affairs and professional standards printed name sign and date eeo complaint form, rev. By signing this document, i declare that i have completed this form in good faith and my answers and statements contained herewith are true and correct based on my current knowledge. Discrimination, harassment, andor retaliation complaint form. Be careful to change the information the form asks for to fit the facts and circumstances of your case. Ps form 2565, eeo complaint of discrimination in the postal. You must file your complaint at the same eeo office where you received.
The address is provided in the notice of your right to file a formal complaint. They may be a tad bit tedious, for filling them out entails the recalling of hurtful facts. Briefly state the specific claim, personnel action andor event that caused you to file this complaint. This form gives you an idea of how a complaint form should ideally look. Filing a formal complaint of discrimination how to file an amended complaint submit the formal complaint form to the central eeo office or headquarters o f the agency. Please allow this letter to serve as my complaint of discrimination against the u. Call or visit any ofccp district and area office if you have questions about the complaint process, want to discuss your complaint, or would like to learn where to file a complaint. In the first instance, it is the counselor who must advise the complainant on the available remedies. Equal employment opportunity internal complaint process civ 4 1. Use of the dhs form is not required, but is recommended. Dd form 2655, complaint of discrimination in the federal. Adobe image over text searchable portable document format pdf to.
Upon receipt of this notice, you will have 15 calendar days to file a formal eeo complaint. The 45day calendar requirement from effective date of personnel action or of the date of the matter alleged to be discriminatory. A guide to filing an equal employment opportunity complaint csosa. Eeo compliance efforts at brokered stations, as well as any other stations, included on this form. Additionally, i understand that the effective date of filing this complaint is the date this form. The complainants decision on whether to proceed with a formal complaint.
Complaint form the purpose of this form is to assist you when filing a civil rights complaint with the department of the treasury internal revenue service. With all the important segments and subheads in place, the user can further make changes to the form as per his need. If your written complaint is accepted, it will be assigned to an eeo. Call sign facility id number type check applicable box location city, state time brokerage. Eeo counselor will notify immediate supervisor a complaint needs to be processed within 30 days. Only the eeoc administrative judges actually make determinations on whether discrimination occurred. Mixed case complaints are processed similarly to other complaints of discrimination, with the following notable exceptions. I understand that the completion of this form or the filing of a discrimination, harassment, andor retaliationcomplaint does not extend the time for filing a complaint with an outside agency, or in a court of law. Acceptance of a complaint is not based on an assessment of the merits of the claims.
Complaint form for allegations of program discrimiation by. Discrimination is often common at the place of work, particularly among employees who come from different walks of life. The purpose of this form, ssa437bk, is to help you file a complaint. Some of the forms, such as the form for a generic complaint, apply to different types of cases. Eeo complaint of discrimination in the postal service see. You must file a formal complaint within 15 days of. Fcc form 396a broadcast equal employment opportunity model program report fcc form 396c mvpd eeo program annual report fcc form 397 broadcast midterm report fcc form 395a cable television annual employment report this form is suspended and does not need to be filed at this time. The structure of such complaint forms make for a formalized and clear framework of facts, and employers and human resource personnel utilizing these forms are presented with a systematic process for. While technically you do not need a lawyer to file an eeoc complaint, for most. A complaint of employment discrimination form will be provided with your nrf.