DOT Form 1050-12 Request for Mediation

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.

Equal Employment Opportunity

Alternative Dispute Resolution

REQUEST FOR MEDIATION

I request that my complaint be considered for mediation. I understand that the agency is not offering mediation, and that I may not elect mediation until such an offer is made. I further understand that the agency will consider my request, and make an assessment of the complaint’s appropriateness for mediation. If the agency offers mediation, at that time, I will have five calendar days to make an election to participate in the mediation process. If however, I choose not to elect mediation, I may continue processing my EEO Complaint in accordance with 29 CFR, Part 1614.

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Complainant’s Name (Please Print) Date

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Complainant’s Signature DOT Complaint Number

This request will be forwarded to the Operating Administration’s EEO Designated Official or the Departmental Mediation Coordinator (DMC).

NOTE FOR FAA EMPLOYEES

The FAA operates an Alternative Dispute Resolution (ADR) Program separate from the ONEDOT Sharing Neutrals Program (DOT Directive 1010.1A) administered by the Departmental Office of Civil Rights. FAA complainants may use either program. Please indicate your preference regarding the ADR program you wish to utilize in the event mediation is agreed to by both parties.

ONE DOT Sharing Neutrals Program

FAA ADR Program