REQUEST FOR INFORMAL COMPLAINT COUNSELING EEO Discrimination Complaints Office and ADR Alternative Dispute Resolution Office NSWC Carderock Division NSWC Carderock Docket #______________________ Name_____________________________________________________ Date ________________________________ Orgn/Ofc Code___________________________________________ Building/Room________________________ Duty Phone______________ E-mail: ___________________________________ Duty Hours___________________ Are you a Bargaining Unit Member? YES ________ NO _______ If so, and if you elect to participate in ADR, the Union must be informed of the date, time and place of the mediation. Representative: __________________________ Position Title/Series/Grade_________________________________________________________________________ Home Mailing Address ____________________________________________________________________________ _____________________________________________________ ZIP___________________ Home Phone_______________________________________________ SSAN_______________________________ Supervisor's Name, phone ext &email: _______________________________________________________________ DISCRIMINATION BASIS – State specific claim next to the basis (as many as apply to your complaint) _____Race ________________________________ _____Color _______________________________ _____National Origin _______________________ _____Physical Handicap _____________________ _____Mental Handicap ______________________ _____Sex ______________________________________ _____Sexual Harassment: _________________________ _____Age (Over 40) DOB: ________________________ _____Religion __________________________________ _____Reprisal __________________________________ COMPLAINT DESCRIPTION Date(s) of incident(s) or personnel action: __________________________________________________________ Brief summary of complaint (you may continue on the reverse side or attach a description): ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Person(s) responsible for alleged discrimination: ____________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ Requested remedy to resolve my complaint: ____________________________________________________________________________________________ ____________________________________________________________________________________________ Your Rights and Responsibilities 29 Code of Federal Regulations Part 1614, REVISED 9 Nov 99 1. You have the right to a representative of your choice throughout the complaint process including the counseling stage. The EEO specialist is not an advocate for either the aggrieved person or the agency. You must notify this office if you obtain a representative or advise us any time you have a change of representative, to include the mailing address and telephone number of your representative. ___ I have a representative. OR ___ I do not have a representative. Name of Representative: ______________________________________ Phone:________________________ Email Address:_____________________________________________________________________________ 2. You have the right to remain anonymous during the informal complaint process. ___ You MAY use my name during the inquiry. OR ___ You MAY NOT use my name. 3. You are at all times responsible for proceeding with your complaint whether or not you have a representative. This includes your full cooperation with the EEO specialist, investigator, and others involved with the processing of your complaint. You are entitled to a reasonable amount of official time to present your complaint; however, you should coordinate time away from your duty station with your supervisor. 4. You have the right to choose between Alternative Dispute Resolution (ADR) or EEO counseling. If you agree to participate in ADR, a written notice terminating the counseling period will be issued upon completion of the dispute resolution process or within ninety (90) calendar days of the first contact with the EEO specialist, whichever is earlier. ____ I elect to participate in ADR. OR ____ I elect to process my complaint through the EEO process. 5. Where you agree to participate in an established ADR program, the written notice terminating the counseling period will be issued upon completion of the dispute resolution process or within ninety (90) calendar days of the first contact with the EEO specialist, whichever is earlier. 6. Informal complaint counseling will be completed within 30 calendar days unless you agree to an extension in writing. If you are not satisfied with the results of the informal complaint counseling you have the right to file a formal complaint within 15 calendar days. You will be provided a notice terminating the counseling stage and informing you of: a. the right to file a formal individual or class complaint within 15 calendar days of receipt of the notice, b. the appropriate official with whom to file a formal complaint, and c. your duty to immediately inform the agency if you retain counsel or a representative. 7. You are required to file a formal complaint within 15 calendar days of receipt of the Counselor's notice of right to file a formal complaint in the event that you wish to file a formal complaint at the conclusion of counseling or ADR. 8. Only claims raised at the counseling stage or claims that are like or related to them may be the subject of a formal complaint, or an amendment to a complaint after it has been filed. 9. Following the EEO investigation of your formal complaint, you have the right to request a hearing by the EEOC. You have the right to appeal the final Navy decision on your formal complaint. You must furnish the EEO office copies of any appeal papers. 10. If you have filed two or more complaints, the agency must consolidate them after appropriate notice to you. 1614.606 When a complaint has been consolidated with one or more earlier complaints, the agency shall complete its investigation within the earlier of 180 days after the filing of the last complaint or 360 days of the filing of the first complaint. INITIALS_________ 11. You have the right to an immediate final decision after an investigation by the agency in accordance with 1614.108(f). 12. Your rejection of an agency's offer of resolution made pursuant to 1614.109(c) may limit the amount of attorney's fees or costs you can recover. 13. You have the right to request a hearing before an EEOC Administrative Judge (except in a mixed case) after completion of the investigation or 180 calendar days from the filing of a formal complaint, whichever comes first. After 9 Nov 99, your request should be made directly to the appropriate EEOC office, and you must notify the responding agency of your hearing request. The appropriate EEOC office for NSWC Carderock Division (Bethesda, MD) is: EEOC Baltimore District Office, 10 South Howard St, 3rd Floor, Baltimore MD 21201 and NSWC Carderock Division (Philadelphia, PA) is EEOC Philadelphia District Office, EEOC Hearings Unit, 21 S. 5th Street, Suite 400, Philadelphia, PA 19106. A copy of your hearing request must also be sent to the EEO office at NSWC Carderock Division. The address is: 5001 S. Broad Street, Code 3240, PNBC, Philadelphia, PA 19112-1403. You must also keep the EEO office and the EEOC informed of any change in your status, i.e., duty location, telephone number, mailing address, etc. and serve copies of hearing requests and/or appeals on the agency [NSWC EEO office]. 14. You have the right to go to U.S. District Court 180 calendar days after filing a formal complaint if no final action has been taken on the complaint, or 180 days after filing an appeal if no decision has been issued on the appeal. 15. You must mitigate damages, i.e., you must look for other appropriate employment and you must seek treatment for any injury you claim. 16. You have the right to file a grievance under the Negotiated Grievance Procedure, if you are a member of the collective bargaining unit. If you are not a member of the bargaining unit, you may file a grievance under the Navy’s administrative grievance procedures. In either case; however, you cannot file a grievance and a formal EEO complaint on the same issues. ___ I have filed a grievance on this matter. OR ___ I have not filed a grievance on this matter. 17. You have the right to file a mixed case complaint or a mixed case appeal, but not both, if the action(s) complained about is(are) appealable to the Merit Systems Protection Board (MSPB). ___ I have filed an appeal on this matter. OR ___ I have not filed an appeal on this matter. 18. If you are alleging age discrimination (over 40 years of age), you have the right to file an administrative complaint under 29 CFR 1614.201(a) or to bypass the administrative complaint process and file a civil action in a U.S. District Court. If you choose civil action, you must give the EEOC not less than 30 days notice of your intent to file such an action. This notice must be filed in writing within 180 days of the occurrence of the alleged unlawful practice to this address: EEOC at P O Box 19848, Washington DC 20036 or by personal delivery or facsimile within 180 days of the occurrence of the alleged unlawful practice. 19. You have the right to go directly to a court of competent jurisdiction on claims of sex-based wage discrimination under the Equal Pay Act even though such claims are also cognizable under Title VII. INITIALS________ STATEMENT OF UNDERSTANDING I received and understand the EEO complaint procedures and my rights and responsibilities. I agree the issues and bases of discrimination listed above fully represent my complaint. I understand contact with the Discrimination Complaints Office must occur within 45 days of the actions I am complaining about. I have not addressed the issues identified above in an appeal to the Merit Systems Protection Board (MSPB), nor in a written grievance under the negotiated grievance procedures, nor have I raised them in a previous EEO complaint. I elect to have the issues in this complaint processed in accordance with 29 CFR 1614 procedures, including the informal counseling process and assignment of an EEO counselor. If I have questions, I will contact the Complaint's Manager at (215) 897-7788 or DSN 443-7788. ______________________________________________ Complainant’s Signature ____________________________ Date ______________________________________________ Complaint's Manager Signature ____________________________ Date Received _______________________________________________ Forwarded to EEO Counselor Authority: Principle Purposes: Routine Uses: Disclosure: Dec 03 ____________________________ Date PRIVACY ACT STATEMENT Title VII, United States Code. To establish the case records and to assist in the processing of the complaint. Used when needed by EEO officials, hearing examiners, investigators, and arbitrators, or by representatives of the Equal Employment Opportunity Commission, and the courts concerning the complaint and appeal. Disclosure is voluntary. If the individual does not furnish the information requested, there will be no adverse consequences. However, failure to furnish the information required on the form may delay or impair processing of the complaint.