Form ETA 9039 ETA 9039 EEO Complaint Form, Apprenticeship Programs

U.S. Department of Labor

Employment and Training Administration

Office of Apprenticeship

OMB Approval No. 1205-0224

Expiration Date: XX/XX/XXXX

Complaint Form – Equal

Employment Opportunity in Apprenticeship 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. This form constitutes notification that a formal Equal Employment Opportunity Complaint is being filed with the U.S. Department of Labor (USDOL).

Privacy Act Notice: The Privacy Act of 1974 requires that the USDOL provide the following statements to each individual from whom it requests information.

The authority for collecting this information is the National Apprenticeship Act of 1937.

The submission of this information is voluntary.

The information is used to process complaints under the above Act.

A copy of this complaint will be provided to the sponsor against whom it is filed. The information collected may be verified with persons who have knowledge pertinent to the complaint, may be used in the course of settlement negotiations with the sponsor and/or in the course of presenting evidence at a hearing, or may be disclosed to other agencies with jurisdiction over the complaint. Only the text of your complaint will be disclosed to the Sponsor and/or Employer. Your actual name and address will not be disclosed.

Failure to provide the information will restrict the action the USDOL can take on your behalf.

Non-Retaliation: Federal (Office of Apprenticeship, “OA”) regulations 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 the OA State Representative immediately if any alleged attempt at retaliation is made and file a Complaint Form.

All complaints must be filed within 180 days of the alleged discrimination or alleged failure to follow equal opportunity standards. Exceptions to this time frame must be fully justified and approved by the Department.

Name of Complainant:

Street Address:

City:

State: ZIP Code:

Telephone No:

Apprenticeship Program Sponsor:

Street Address:

City: State: ZIP Code:

Date of discrimination or failure to follow equal opportunity standards:

Bases: (Please review definitions on pages 2 - 3.)

Check mark one, any, or all of the appropriate basis (bases) you believe was (were) discriminatory.

1. Race 2. Color 3. Religion 4. Sex 5. Sexual Orientation 6. Gender Identity

7. National Origin 8. Age 9. Genetic Information 10. Disability

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THE COMPLAINT

Describe in detail the alleged discriminatory act(s) or alleged failure to follow equal opportunity standards, indicating place, names and titles or person involved. (Additional pages may be added to this form.)

Signature and Date of Complainant or Complainant’s Authorized Representative:

_____________________________________________Date:________________

Please mail your complaint to the OA State Office or the State Registration Agency.

DEFINITION OF BASES:

1. RACE

a. American Indian or Alaska Native A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

b. Asian A person having origins in any of the original people of the Far East, Southeast Asia, or the Indian subcontinent (e.g., Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.)

c. Black or African American A person having origins in any of the black racial groups of Africa.

d. Native Hawaiian or A person having origins in any of the people of Hawaii, Guam, Samoa, or other

Other Pacific Islander Pacific Islands.

e. White A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

2. COLOR (Different than Race) One’s skin color or complexion (e.g., light-skinned or dark-skinned complexion).

3. RELIGION One’s religious practice or belief (traditional, e.g., Buddhism, Christianity, Hinduism, Islam, and Judaism) and also others who have sincerely held religious, ethical, or moral beliefs.

4. SEX A person’s sex as biological male or biological female (biological differences

between a male or a female).

5. SEXUAL ORIENTATION An individual’s physical, romantic, and/or emotional attraction to people of the same and/or opposite gender. Examples of sexual orientations include straight (or heterosexual), lesbian, gay, and bisexual.

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6. GENDER IDENTITY An individual’s internal sense of being male or female and may or may not conform

to social stereotypes associated with a particular gender.

Transgender individuals are persons with a gender identity that is different from the

sex assigned to them at birth (e.g. an individual assigned the male sex at birth but

identifies as female is a transgender woman; an individual assigned the female sex

at birth but identifies as a male is a transgender man.

Transition: Some individuals will find it necessary to transition from living and

Working as one gender to another. Some of these individuals often seek some form

of medical treatment (e.g. counseling, hormone therapy, electrolysis and

reassignment surgery).

7. NATIONAL ORIGIN An individual is from a particular country or part of the world, because of ethnicity or accent, or because the individual appears to be of a certain ethnic background (even if the individual is not).

8. AGE A person is 40 years or older.

9. GENETIC INFORMATION Means (a) information about (1) An individual’s genetic tests; (2) The

genetic tests of that individual’s family members; (3) The manifestation of disease

or disorder in family members of the individual (family medical history); (4) An

individual’s request for, or receipt for, or receipt of, genetic services, or the

participation in clinical research that includes genetic services by the individual or

a family member of the individual or (5) The genetic information of a fetus

carried by an individual or by a pregnant woman who is a family member of the

individual and the genetic information of any embryo legally held by the

individual or family member using an assisted reproductive technology.

(b) Genetic information does not include information about the sex or age of the

individual, the sex or age of family members, or information about the race or ethnicity of the individual or family members that is not derived from a genetic test.

10. DISABILITY Means, with respect to an individual: (a) a physical or mental impairment that

substantially limits one or more major life activities of such individual; (b) a record

of such an impairment; or (c) being regarded as having such an impairment.

The collection and maintenance of the data on ETA-9039, Complaint Form – Equal Employment Opportunity in Apprenticeship Programs, is authorized under the National Apprenticeship Act, 29 U.S.C. 50, CFR 29 Part 29.1, and CFR 29 Part 30.14. The data is used for apprenticeship program statistical purposes and is maintained, pursuant to the Privacy Act of 1974 (5 U.S.C. 552a.). Data may be disclosed to a State Apprenticeship Agency to determine an assessment of skill needs and program information, and in connection with federal litigation or when required by law.

Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Public reporting burden for this collection of information, which is voluntary, is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information. While use of this form is optional, a fully completed Form ETA-9039 provides the information required by CFR 29 Part 30.14 to request an investigation of your complaint.  The regulations require that all EEO complaints under apprenticeship training programs be in writing. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employment and Training Administration, Office of Apprenticeship, Room N-5311, Washington, D.C. 20210. (Paperwork Reduction Project 1205-0224).

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