Form DHS Form 3090 DHS Form 3090 DHS Individual Compliant of Employment Discrimination

OMB No. 1610-0001 Expiration Date: 8/31/14
FOR OFFICIAL USE ONLY

DEPARTMENT OF HOMELAND SECURITY

INDIVIDUAL COMPLAINT OF EMPLOYMENT DISCRIMINATION
(Use this form for original complaints and amendments.)

FILING DATE

PART I COMPLAINANT IDENTIFICATION

5. NAME AND ADDRESS OF ORGANIZATION WHERE YOU
WORK (If a Department of Homeland Security Employee)

1. NAME (Last, First, Middle Initial)
2. TELEPHONE/FAX (Include Area Code)
Home
Fax
Work

DEPARTMENT CASE NUMBER

Bureau or Component
Office and Organizational Unit

Fax

3. HOME ADDRESS (You must notify the Department of any
change of address while complaint is pending, or your
complaint may be dismissed.)

Street Address
City

State

Zip Code

6. EMPLOYMENT STATUS IN RELATION TO THIS COMPLAINT
4. IF YOU ARE A CURRENT OR FORMER EMPLOYEE OF THE
FEDERAL GOVERNMENT, LIST YOUR RECENT TITLE,
SERIES, AND GRADE.
Title

Series

Applicant

Probationary

Uniformed Service Member
Former Employee/Member

Grade

Career/Career Conditional

Date Left Department

Retired
Date of Retirement
Other (Specify)

7. I certify that all 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

8. 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 DEPARTMENT IMMEDIATELY IN WRITING OF ANY
CHANGE, AND YOU MUST INCLUDE THE SAME INFORMATION REQUESTED IN THIS PART.
to serve

"I hereby designate (Please Print Name)

as my representative during the course of this complaint. I understand that my representative is authorized to act
on my behalf."
Is the representative an attorney?
9. REPRESENTATIVE'S MAILING ADDRESS
FIRM/ORGANIZATION

YES

NO

10. REPRESENTATIVE'S EMPLOYER (If Federal Agency)

STREET ADDRESS

11. REPRESENTATIVE'S TELEPHONE/FAX (Include Area Code)
Fax
Telephone

CITY, STATE, & ZIP CODE

12a. COMPLAINANT'S SIGNATURE

DHS Form 3090-1 (5/14)

12b. DATE

Page 1 of 2

PART III ALLEGED DISCRIMINATORY ACTIONS
13. NAME OF PERSON OR DHS COMPONENT WHO TOOK THE 14. ARE YOU WILLING TO PARTICIPATE IN MEDIATION OR
OTHER AVAILABLE TYPES OF ALTERNATIVE DISPUTE
ACTION AT ISSUE.
RESOLUTION TO RESOLVE YOUR COMPLAINT?
FIRM/ORGANIZATION
STREET ADDRESS

YES

CITY, STATE, & ZIP CODE

NO

15. A. Describe the action taken against you that you believe was discriminatory.
B. Give the date when the action occurred, and the name of each person responsible for the action.
C. Describe how you were treated differently from other employees, applicants, or members for any of the reasons listed in
Item 16.
D. Indicate what harm, if any, came to you in your work situation as a result of this action. (You may, but are not required to,
attach extra sheets.)
E. If the basis of your complaint is parental status or sexual orientation, use this form, but your complaint is not statutorily based
and will follow separate, parallel process.

16. Mark below ONLY the bases you believe were relied on to take the actions described in Item 15.
RACE (Specify)

AGE (Date of Birth)
PHYSICAL OR MENTAL DISABILITY (Describe)

COLOR (Specify)
RELIGION (Specify)

RETALIATION/REPRISAL (Dates of Prior EEO Activity)

NATIONAL ORIGIN (Specify)

GENETIC INFORMATION

SEX (Specify)

SEXUAL ORIENTATION

Pregnancy

Gender Identity

PARENTAL STATUS

17. WHAT REMEDIAL OR CORRECTIVE ACTION ARE YOU SEEKING TO RESOLVE THIS MATTER

18. ON THIS SAME MATTER, HAVE YOU FILED A GRIEVANCE OR APPEAL UNDER:
Negotiated grievance procedure
Agency grievance procedure
Merit Systems Protection Board appeal procedure
If you filed a grievance or appeal, provide date filed, case number, and present status.

YES

NO

YES

NO

YES

NO

PART IV CONTACT
EEO/EO Counseling is not required if you are requesting amendment of an existing, open complaint.
Complete items 24 and 25, even if you did not contact a counselor.
19. DATE YOU CONTACTED AN EEO COUNSELOR

20. NAME AND TELEPHONE NUMBER OF EEO COUNSELOR
Name

Phone

21. DID YOU DISCUSS ALL ACTIONS RAISED IN ITEM 15 WITH 22. DATE YOU RECEIVED YOUR "NOTICE OF RIGHT TO FILE"
AN EEO COUNSELOR? (If NO, explain on attached sheet)

YES

NO

23. IF YOU ARE REQUESTING AMENDMENT OF AN EXISTING, OPEN, FORMAL COMPLAINT (OR PROVIDING ADDITIONAL
EVIDENCE), INDICATE THE COMPLAINT CASE NUMBER OF THAT COMPLAINT.
24. DATE OF MOST RECENT DISCRIMINATORY EVENT

DHS Form 3090-1 (5/14)

25. DATE YOU FIRST BECAME AWARE OF THE ALLEGED
DISCRIMINATION

Page 2 of 2

OMB No. 1610-0001 Expiration Date: 8/31/14
DEPARTMENT OF HOMELAND SECURITY
DHS FORM 3090-1, 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 Homeland
Security (DHS), or as a present or former Department of Homeland Security 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,
genetic information or in reprisal for opposition to activities protected by civil rights statutes, or
participation in proceedings to enforce those statutes; or

2.

believe you have been discriminated against because of your parental status or sexual orientation. Your
claim is not covered under statutory basis, but will be processed under a parallel procedure, and

3.

have presented the matter for informal resolution to an Equal Employment Opportunity (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. If you are amending or providing additional evidence to an existing open complaint,
the form should be used, but EEO counseling is not required.

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 CFR 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" 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, EEO Investigator 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: In accordance with 29 CFR 1614.106(c), your written complaint must be signed by you or your
attorney. The complaint should be filed with the EEO Director of the Department of Homeland Security component
where the alleged discrimination occurred. (Filing instructions are contained in the "Right to File" form, which was
provided by your Counselor.) Keep a copy of the completed complaint form for your records.

PRIVACY ACT STATEMENT
1.

FORM/TITLE/DATE: Department of Homeland Security (DHS) DHS Form 3090-1, Individual Complaint of
Employment Discrimination with the Department of Homeland Security.

2.

AUTHORITY: 42 USC 2000e; 29 USC 633a; 5 USC 1303 and 1304; 5 CFR 5.2 and 5.3; 29 CFR 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 Homeland Security on the grounds of race, color, religion, sex, national
origin, age, physical or mental disability, protected genetic information, or retaliation. Information provided on this
form will be used by DHS to determine whether the complaint was timely filed and whether the allegations in the
complaint are within the purview of 29 CFR Part 1614, to provide a factual basis for investigation of the complaint,
and to reach a decision on the complaint. It also records an amendment or additional evidence to an open,
pending complaint.

4.

ROUTINE USES: Other disclosures may be:

5.

a.

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

b.

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

c.

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

d.

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.

WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY, AND EFFECT OF 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 Homeland Security dismissing the complaint. It is not mandatory that this form be
used to provide the requested information.

OMB STATEMENT
In accordance with the Paperwork Reduction Act, no persons are required to respond to a collection of information
unless it displays a valid OMB Control Number. The valid OMB Control Number for this information collection is
1610-0001. The time required to complete this information collection 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 collection of information.