Form CC-4 Complaint of Discrimination in Employment-OFCCP Complain

Complaint of Discrimination in Employment Under Federal Government Contracts Un

U.S. Department of Labor Office of Federal Contract Compliance Programs

Instructions: Before completing this form, please read all instructions, including the Privacy Act statement below. Use this form to file a complaint of discrimination in employment under any of the OFCCP programs. While your response is voluntary, OFCCP relies on this information as a source for identifying potential violations of equal employment opportunity requirements in the federal contractor community. Note: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.

OMB No: 1250-0002 Expires:

Privacy Act Notice: The authority for collecting this information is Executive Order 11246, as amended, Sec. 503 of the Rehabilitation Act of 1973, as amended; the Vietnam Era Veterans’ Readjustment Assistance Act of 1974 as amended, 38 U.S.C. 4212; Title VII of the Civil Rights Act of 1964, as amended; and/or Title I of the Americans with Disabilities Act of 1990, as amended (ADA). This information is used to process complaint and conduct investigations of alleged violations of the above Order or Acts. We will provide a copy of this complaint to the employer against whom it is filed and, when matters alleged are covered by Title VII and/or the ADA, to the U.S. Equal Employment Opportunity Commission (EEOC). The information collected may be verified with others who may have knowledge relevant to the complaint. It may be used in settlement negotiations with the employer or in the course of presenting evidence at a hearing, or may be disclosed to other agencies with jurisdiction over the complaint. Providing this information is voluntary; however failure to provide the information will restrict the action that the Department of Labor can take on your behalf and, for matters covered by Title VII or the ADA, may affect your right to sue under those laws.

Non-Retaliation: OFCCP regulations and Title VII and/or the ADA where applicable, require an employer to take all necessary steps to assure that there is no retaliation against any person who files a complaint or assists in its investigation. This includes any intimidation, threat, coercion or discrimination. Please notify OFCCP immediately if any alleged attempt at retaliation is made.

Prompt Filing: All complaints must be filed within a specified number of days following the latest occurrence of the alleged discrimination: Executive Order 11246 – 180 days; Rehabilitation and Veterans Acts – 300 days. Exceptions must be approved by the Director.

Name and address: Name ___________________________________________ Address _________________________________________ City ___________________ State _______ Zip __________	Name and address of company you allege discriminated against you: Name ___________________________________________ Address _________________________________________ City ___________________ State _______ Zip __________
Telephone No._________________________	Telephone No._________________________
Mail this form to the Department of Labor, OFCCP Regional Office:	Give the date(s) of the latest occurrence(s) of the alleged discriminatory act(s): _____________ ______________ _____________

Step 1: Check the box next to the program you are filing under (i.e. Executive Order 11246, as amended; Section 503 of the Rehabilitation Act of 1973, as amended, or the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended, 38 U.S.C. 4212, or retaliation)

Step 2: Under the program, check what you believe to be the basis for the discrimination against you, such as race, sex, or national origin. If you think that thee was more than one basis, more than one basis may be checked. You may also check more than one race/ethnic category.

___ Executive Order 11246, as amended. This Order covers persons alleging discrimination because of race, color, religion, sex, or national origin. If this is checked, your complaint will be dual filed as a charge under Title VII of the Civil Rights Act of 1964. I believe I was (or continue to be) discriminated against because of my:

Bases:

__Race	__Hispanic or Latino	__ American Indian or Alaskan Native
__Color	__Not Hispanic or Latino	__ Asian
__Religion		__ Black or African American
__Sex ___Female ___Male		__ Native Hawaiian or Other Pacific Islander
__National Origin		__White
__Other

___ Section 503 of the Rehabilitation Act of 1973, as amended. This Act covers individuals with a disability, persons with a history of physical or mental disability, and persons regarded as disabled by the employer. If this is checked, your complaint will be dual-filed as a charge under the Americans with Disabilities Act.

Basis ____ Disability Please check if you are a veteran: ______ Yes ______ No

___ Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended, 38 U.S.C. 4212. This Act covers special disabled veterans, veterans of the Vietnam Era, recently separated veterans, disabled veterans, Armed Forces service medal veterans, and other protected veterans.

___ Retaliation: It is unlawful to harass intimidate, threaten, coerce, or discriminate against any individual because he or she has filed a complaint, participated in a discrimination proceeding or otherwise opposed discrimination under any of the federal programs above.

Form CC-4

If your complaint is based on Veteran Status, Check one or more of the following applicable box(es).

___ I was discharged or released from active duty on (enter date of discharge or release) _______________

___ I am a veteran who, while serving on active duty in the Armed Forces, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985 (61 CFR 1209).

___ I served on active duty during a war or in a campaign or expedition for which a campaign badge has been authorized.

___ I served on active duty for a period of more than 180 days, and was discharged or released with other than a dishonorable discharge, and the active duty occurred in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or between August 5, 1964, and May 7, 1975 in all other cases.

___ I was discharged or released from active duty for a service connected disability. If you have checked this box, submit medical information resulting in discharge or release with this form. (This information is available from your Master Military Record at the National Personnel Record Center, 9700 Page Boulevard, St. Louis, MO 63132.)

I am a veteran who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs. Check one of the following:

_

__ Disability rating of 30% or more

___ Disability rating at 10% or 20% and have been officially determined to have a serious employment disability

___ Disability rating, but neither a or b

Step 3: Check those actions which you believe the employer took or failed to take because of your race, color, religion, sex, national origin, disability or veteran status (more than one may be checked):

Issue(s):

___ Hiring	___ Promotion	___ Job Assignment	___ Sabbath Day Observance
___ Termination	___ Demotion	___ Training and Apprenticeship	___ Intimidation
___ Layoff	___ Seniority	___ Segregated Facilities	___ Other ______________
___ Recall	___ Harassment	___ Pregnancy Leave
___ Wages	___ Job Benefits	___ Accommodation to Disability

For each issue, explain in your statement below how you were discriminated against.

1. Do you know any other employees or applicants of your group who were treated in the same way (checked above) you allege you were?

___ Yes ___ No If yes, include their names in your statement below and explain how they were treated.

2. Do you know any other employees or applicants who are not of your group who were treated in the same way (checked above) you allege you were?

___ Yes ___ No If yes, include their names in your statement below and explain how they were treated.

The Complaint

Describe in detail the alleged discriminatory/retaliatory act (s).

Please include:

• Why you believe the act(s) was because of your disability, veteran status, race, color, religion, sex, or national origin, and why you believe the act(s) was retaliation;

• Dates, places, names and titles of persons involved and witnesses, if any;

• What harm, if any, was caused to you or others with whom you work as a result of the alleged discriminatory act(s);

• What explanation, if any, was offered for the act(s) by the employer; and

• Any information you may have on federal contracts held by the employer.

If this is a complaint based on disability, describe the disability, your history of disability, or why you think the employer regarded you as disabled.

(Type as much information as required into the block above)

If you have sought assistance in resolving this complaint from another source (another agency, a lawyer, internal grievance procedure, etc.) please indicate here and the name of the source, the date you sought assistance, and result, if any:

Name __________________________________________________________________________ Date ___________________

Result:

Friend or Relative:

Please notify OFCCP if you change your address or phone number. You may indicate a person who would know how to reach you if OFCCP is unable to reach you at your own address or phone.

Name_________________________________________________

Address _______________________________________________

City ___________________________ State _______ Zip ________

Relationship ____________________________________________

Telephone ______________________________________________

FILED ELSEWHERE? If you have filed this complaint or a similar one elsewhere, please tell us: Name ___________________________________________ Address _________________________________________ City ___________________ State _______ Zip __________ Contact __________________________________________ Telephone ________________________________________

ARE YOU REPRESENTED? If you are represented by an attorney or other person or organization, please tell us: Name ___________________________________________ Address _________________________________________ City ___________________ State _______ Zip __________ Contact __________________________________________ Telephone ________________________________________

SIGNATURE AND VERIFICATION

I declare under penalty of perjury that the information given above is true and correct to the best of my knowledge or belief. (A willful false statement is punishable by law: 18 U.S.C. 1001.) I hereby authorize the release of any medical information needed for the investigation.

____________________________________________ __________________________

Signature of Complainant Date

Public Burden Statement

We estimate that it will take an average of 1.28 hours to complete this complaint form, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information. If you have any comments regarding these estimates or any other aspect of this complaint form, including suggestions for reducing this burden, send hem to the Office of Federal Contract Compliance Programs Policy Division (1250-0002) 200 Constitution Avenue, N.W., Room C3310, Washington, D.C. 20210.

DO NOT SEND THE COMPLETED FORM TO THIS OFFICE

Do not write below this line

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The complainant has verified this complaint in my presence. This complaint is now the basis of an investigation under Executive Order11246, as amended; Section 503 of the Rehabilitation Act of 1973, as amended; and/or the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended (38 U.S.C. 4212).

________________________________ ____________________ ________________________ ________________________

Name of Investigator Title Signature of Investigator Date

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