DOT Form 1050-5 Extension of EEO Counseling

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: EXTENSION OF EEO COUNSELING

In accordance with § 1614.105(e) of the Equal Employment Opportunity Commission (EEOC) Regulations (29 C.F.R. Part 1614), the undersigned agree to postpone the final interview on the matter(s) upon which EEO Counseling commenced on ________________.

(Date)

It is understood that counseling may extend for a period of 60 days from the date of this Agreement [not more than 60 days beyond the end of the 30-day period allowance for counseling]. If counseling is completed prior to the end of the period stated above, and the matter(s) remains unresolved, a “Notice of the Right to File a Discrimination Complaint” will be provided. I understand this is merely an extension of the counseling period. It does not compromise my right to file a formal discrimination complaint.

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Signature of Aggrieved Individual Date

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Signature of Representative Date

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Signature of EEO Official Date