DOT Form 1050-8 Individual Complaint of Employment

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 1 hour 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.

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, sexual orientation, genetic information, pregnancy discrimination act of 1978 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, S.E., 76-401, 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)

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PRIVACY ACT STATEMENT

1. FORM NUMBER/TITLE DATE: Department of Transportation Form Number 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, genetic information 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:

1. to respond to a request from a Member of Congress regarding the status of the complaint or appeal;

2. to respond to a court subpoena and/or to refer to a district court in connection with a civil suit;

3. to disclose information to authorized officials or personnel to adjudicate a complaint or appeal;

4. 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

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INDIVIDUAL COMPLAINT OF EMPLOYMENT DISCRIMINATION WITH THE DEPARTMENT OF TRANSPORTATION				FOR OFFICE USE ONLY
				DEPARTMENT CASE NUMBER
				FILING DATE
PART I COMPLAINANT IDENTIFICATION INFORMATION
Name (Last, First, Middle Initial)		5a. Name and Address of Organization Where You Work (If a Department of Transportation Employee) Office and Staff Symbol Street Address City State Zip Code
Telephone/Fax (Include Area Code) H ome: Fax: __________________________________________ W ork: 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 City State Zip Code
		5b. Last four digits of your Social Security Number:
		6. Employment Status in Relation to this Complaint: □ Applicant □ Probationary □ Career/Career Conditional □ Former Employee______________________________ Date Last Employed at Department □ Retired _____________________________ Date of Retirement □ Other _____________________________ Specify
If you are a current or former employee of the federal government, list your most recent title, series, and grade. 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 Date
PART II DESIGNATION OF REPRESENTATIVE
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.
9. Representative’s Mailing Address Firm/Organization Street Address City State Zip Code		10. Representative’s Employer (If Federal Agency)
		11. Representative’s Telephone/Fax (Include Area Code) _________________________________________________ Telephone: Fax:
		12. COMPLAINANT’S SIGNATURE DATE
	PART III ALLEGED DISCRIMINATORY ACTIONS
	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 Zip Code		If your complaint involves nonselection for a position, please complete the following: Position Title Series Grade Vacancy Announcement No. Date Learned of Nonselection
	(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, genetic information, 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.)
	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) _______________________ □ Genetic Information ________________________ □ Pregnancy Discrimination Act of 1978 ________________________
	What remedial or corrective action are you seeking?
	PART IV COUNSELOR CONTACT
	When did the most recent discriminatory event occur? _________________________________________________ Month Day Year		When did you receive your Notice of Right to File? ___________________________________________ Month Day Year
	19. When did you first become aware of the alleged discrimination? _______________________________ Month Day Year		On this same matter, have you filed a grievance or appeal under: Negotiated Grievance procedures □ YES □ NO Agency grievance procedure □ YES □ NO MSPB appeal procedure □ YES□ NO If you filed agrievance or appeal, provide date filed, case number, and present status. ____________________________________________________
	When did you contact an EEO counselor? _________________________________________________ Month Day Year
	Did you discuss ALL actions raised in item 15 with an EEO Counselor? □ YES □ NO (If no, explain on attached sheet)
	Name and Telephone number of EEO Counselor ______________________________ ______________ Name Telephone No.

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