Form F1050-8 Individual Complaint of Employment Discrimination Form

OMB No: 2105-0556
Expiration Date: mm/dd/yyyy
PAPERWORK REDUCTION ACT BURDEN STATEMENT
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure
to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that Control Number for this
information collection is 2105-0556. Public reporting for this collection of information is estimated to be approximately 1 hour per response,
including the time for reviewing instructions, completing and reviewing the collection of information. All responses to this collection of
information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden to the U.S. Department of Transportation, Departmental Office of Civil Rights (S-30), 1200 New Jersey
Avenue, SE; Washington, DC 20590.

DEPARTMENT OF TRANSPORTATION
INDIVIDUAL COMPLAINT OF EMPLOYMENT DISCRIMINATION
FORM INSTRUCTIONS
(Read the following instructions carefully before you complete this form)
(Please complete all items on the complaint form)
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, genetic information,
sexual orientation 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, SE, W76-401; 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.
(PLEASE ALSO READ THE PRIVACY ACT STATEMENT ON THE REVERSE SIDE)
DOT F 1050-8

PRIVACY ACT STATEMENT
1. FORM NUMBER/TITLE DATE: Department of Transportation Form Number DOT F 1050-8,
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
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.
DETACH AND KEEP THIS PAGE WHEN YOU FILE YOUR COMPLAINT

DOT F 1050-8

FOR OFFICE USE ONLY

DEPARTMENT OF TRANSPORTATION
INDIVIDUAL COMPLAINT OF EMPLOYMENT
DISCRIMINATION WITH THE DEPARTMENT OF
TRANSPORTATION

PART I
1.

DEPARTMENT CASE NUMBER
FILING DATE

COMPLAINANT IDENTIFICATION INFORMATION

Name (Last, First, Middle Initial)

5a. Name and Address of Organization Where You Work (If a
Department of Transportation Employee)

2.

Telephone/Fax (Include Area Code)

Home:
Fax:
__________________________________________
Work:
Fax:
E-Mail:
3. Present Home Address (You must notify the
Departmental Office of Civil Rights of any changes of
address while complaint is pending, or your complaint may
be dismissed)
Street Address

Office and Staff Symbol
Street Address
City

Zip Code

5b. Last four digits of your Social Security Number:
6. Employment Status in Relation to this Complaint:
□ Applicant

City

State

State

□ Probationary

□ Career/Career Conditional

Zip Code

4. If you are a current or former employee of the
federal government, list your most recent title, series,
and grade.

□ Former Employee______________________________
Date Last Employed at Department
□ Retired
_____________________________
Date of Retirement
□ Other
_____________________________
Specify

Title
Series
Grade
7. I certify that all of the statements made in this complaint are true, complete, and correct to the best of my knowledge and
belief.

Signature of Complainant or ATTORNEY Representative
PART II DESIGNATION OF REPRESENTATIVE

Date

8. You may represent yourself in this complaint or you may choose someone to represent you. Your representative does not
have to be an attorney. You may change your designation of a representative at a later date, but you must notify the
Departmental Office of Civil Rights immediately in writing of any change, and you must include the same information
requested in this Part.
“I hereby designate ___________________________________________________(Please Print Name)_ to serve as my
representative during the course of this complaint. I understand that my representative is authorized to act on my behalf.
10. Representative’s Employer (If Federal Agency)
9. Representative’s Mailing Address
Firm/Organization

11. Representative’s Telephone/Fax
(Include Area Code)

Street Address
City

State

Zip Code

_________________________________________________
Telephone:
Fax:

12. COMPLAINANT’S SIGNATURE
DOT F 1050-8

DATE

PART III ALLEGED DISCRIMINATORY ACTIONS
13.
Name and Address of Agency/office that took the
action at issue (if different than item 5.)
Office and Organizational Component
___________________________________________
Street Address
City

State

14.
If your complaint involves nonselection for a position,
please complete the following:

Position Title

Series

Grade

Zip Code

Vacancy Announcement No.
Date Learned of
Nonselection
15.
(A) Describe the action taken against you that you believe was discriminatory; (B) Give the date the action occurred,
and the name of each person responsible for the action; (C) Describe how you were treated differently than other employees
or applicants because of your race, color, religion, sex, national origin, age, disability, or in retaliation for your participation
in the EEO process or opposition to alleged discriminatory practices; (D) indicate what harm, if any, came to you in your
work situation as a result of this action. (You may attach extra sheets.)

16.
Mark below ONLY the bases you believe were relied on to take the actions described in #15.
Race (State Race) ____________________________
□ Mental Disability (Specify) _________________________
Color (State Complexion) _____________________
□ Physical Disability (Specify) ________________________
Religion (State Religion) _______________________
□ Retaliation/Reprisal (Dates of prior EEO Activity)
Sex (State Sex) _______________________
______________________________________________
National Origin (Specify) _______________________
□ Sexual Orientation (Specify) _______________________
Age (Date of Birth) _______________________
17.
What remedial or corrective action are you seeking?

□
□
□
□
□
□

PART IV COUNSELOR CONTACT
18. When did the most recent discriminatory event occur?
_________________________________________________
Month
Day
Year
19. When did you first become aware of the alleged
discrimination?
_______________________________
Month
Day
Year
20. When did you contact an EEO counselor?
_________________________________________________
Month
Day
Year
21. Did you discuss ALL actions raised in item 15 with an
EEO Counselor?
□ YES
□ NO
(If no, explain on attached sheet)
22. Name and Telephone number of EEO Counselor
______________________________ ______________
Name
Telephone No.

DOT F 1050-8

23. When did you receive your Notice of Right to File?

___________________________________________
Month
Day
Year
24. On this same matter, have you filed a grievance or appeal
under:
Negotiated Grievance procedures
Agency grievance procedure
MSPB appeal procedure

□ YES
□ YES
□ YES

□ NO
□ NO
□ NO

If you filed a grievance or appeal, provide date filed, case
number, and present status.

____________________________________________________