DOT Form 1050-6 NOTICE OF RIGHT TO FILE A DISCRIMINATION COMPLAINT

OMB No: 2105-0556

Expiration Date: MM/DD/YYYY

Public 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 collection of information displays a current valid OMB Control Number.  The OMB Control Number for this information collection is 2105-0556.  Public reporting for this collection of information is estimated to be approximately 2.5 hours per respondent, including the time for reviewing instructions, gathering the data needed, and 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: Information Collection Clearance Officer, U.S. Department of Transportation, Room W56-440, 1200 New Jersey Ave, SE, Washington, D.C. 20590.

Privacy Act Statement

The Privacy Act requires that we provide you with the following information regarding our use of your Personally Identifiable Information. The information on this form is solicited under the authority of 29 C.F.R. Part 1614. The purpose of this form is to inform Complainants about the EEO complaint process. Information provided on this form will be used by the Department of Transportation to determine whether the complaint was timely filed, whether the claims in the complaint are within the purview of 29 C.F.R. Part 1614, to provide a factual basis for investigation of the complaint, and to ensure that the proper processes were followed. 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.

Subject: NOTICE OF RIGHT TO FILE A DISCRIMINATION COMPLAINT

From:

To:

This is to inform you that because the matter you brought to my attention has not been resolved, you are now entitled to file a formal discrimination complaint based on race, color, religion, sex, pregnancy, national origin, physical or mental disability, age (40 and over), sexual orientation, genetic information, pregnancy discrimination act of 1978 and/or retaliation.

If you file a complaint, it must be in writing, signed, and filed, in person, by mail (postmarked), or by facsimile, WITHIN 15 CALENDAR DAYS AFTER RECEIPT OF THIS NOTICE, with the following official authorized to receive discrimination complaints:

Associate Director

Compliance Operations Division

Departmental Office of Civil Rights

1200 New Jersey Avenue, S.E., W76-401

Washington, D.C. 20590

Phone: (202) 366-9370

Toll Free: (866) 355-7147

Fax No: (202) 493-2064

Federal Relay: (800) 676-3777

You may also choose to file your formal complaint electronically using the following DOT web address: http://www.docr.dot.gov/ and by clicking on the option labeled, “File a Formal EEO Complaint.”

Please note that when using the E-Formal Filing option, you must complete the form and its submission in one session, the information you input cannot be saved, but you may upload attachments to be included with your electronic submission.

A complaint shall be deemed timely if it is received or postmarked before the expiration of the 15-day filing period, or, in the absence of a legible postmark, if it is received by mail within five days of the expiration of the filing period.

The complaints must be specific and contain only those claims discussed with me. The complaint should have dates for each allegation you make. It must also state whether you have filed a grievance under a negotiated grievance procedure, or an appeal with the Merit System Protection Board on the same claim(s). For your use, a copy of the Complaint of Discrimination in the Federal Government form is provided.

If you retain an attorney or any other person to represent you, you or your representative must immediately notify the Associate Director, Compliance Operations Division, Departmental Office of Civil Rights, in writing. You and/or your Representative will receive a written acknowledgment of your discrimination complaint from the Departmental Office of Civil Rights.

Please note that you may also choose to file your formal complaint electronically. Using the E-Formal Filing option, you must complete the form and its submission in one session, the information you input cannot be saved, but you may upload attachments to be included with your electronic submission.

________________________________________ ________________________

Signature, EEO Counselor Date

I acknowledge receipt of this letter (DATE RECEIVED).

________________________________________ ________________________

Signature, Aggrieved Individual Date

Delivery method of this Notice:

Hand Delivery ____________________________________

Date

Certified Mail ____________________________________

Receipt Tracking Number

Facsimile ___________________________________

Date (please attach confirmation sheet)

Other ___________________________________