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.