Form ETA 9039 ETA 9039 EEO Complaint Form, Apprenticeship Programs

U.S. Department of Labor

Employment and Training Administration

Office of Apprenticeship

Complaint Form – Equal

Employment Opportunity in Apprenticeship Programs

OMB Approval No. 1205-0224

Expiration Date: 05/31/2016

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. To the extent permitted by law, 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 page 2.)

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

1. Race 2. Color 3. Religion 4. National Origin 5. Sex

Page 1 of 2 ETA 9039 (Rev. May 2016)

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 of Complainant and Date:

Please mail your complaint to the OA State Office.

DEFINITION OF BASIS:

1. RACE - Select one or more:

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. Terms such as

“Haitian” or “Negro” can be used in addition to “Black or African American.”

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

Other Pacific Islander other 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/complexion, dark-skinned/ complexion.)

3. RELIGION - One’s religious practice or belief (e.g., Baptist, Buddhist, Catholic, Hindu, Jewish, Moslem, etc.)

4. NATIONAL ORIGIN - An individual’s or his or her ancestor’s place of origin, or because an individual has the physical, cultural or linguistic characteristics of a national origin group [e.g., American Indian; Chinese; Egyptian; Hispanic or Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish-culture or origin, regardless of race.); Italian, etc.]

5. SEX - Male or Female.

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 30.11. The data is used for apprenticeship program statistical purposes and is maintained, pursuant to the Privacy Act of 1974 (5 U.S.C. 552a.), in a system of records entitled, DOL/ETA-4, Registered Apprenticeship Partners Information Management Data System (RAPIDS) at the U.S. Department of Labor, Office of Apprenticeship, 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 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 30.11 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).

Page 2 of 2 ETA 9039 (Rev. May 2016)