Form DOT F 1050–8 DOT F 1050–8 Individual Complaint of Employment

OMB No:

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U.S. Department of Transportation

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 (gender, sexual harassment, pregnancy, sexual orientation, or gender identity), national origin, age (40 years or older at the time of the event giving rise to your claim), physical or mental disability, equal pay/compensation, genetic information, or believe that you have been retaliated against for participating in activities covered under the Equal Employment Opportunity statutes; and

2. have presented the matter for informal resolution to an EEO Counselor within 45-calendar days of the event giving rise to your claim, or within 45-calendar 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., W76-401, Washington, DC 20590. Filing instructions are contained in the Notice of Right to File a Discrimination Complaint 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)

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 (gender, sexual harassment, pregnancy, sexual orientation, or gender identity), national origin, age, physical or mental disability, genetic information, or reprisal, 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

DEPARTMENT OF TRANSPORTATION

INDIVIDUAL COMPLAINT OF EMPLOYMENT DISCRIMINATION WITH THE DEPARTMENT OF TRANSPORTATION

FOR OFFICE USE ONLY

DEPARTMENT CASE NUMBER

FILING DATE

PART I COMPLAINANT IDENTIFICATION INFORMATION

1. Name (Last, First, Middle Initial):

5. Name and Address of Organization Where You Work (If a Department of Transportation Employee):

Office and Staff Symbol:

Street Address:

City: State: Zip Code:

2. Telephone/Fax (Include Area Code):

Home: Fax: __________________________________________

Work: Fax:

E-Mail:

3. Present Home Address (You must notify the Departmental Office of Civil Rights of any changes to your address while the complaint is pending, or your complaint may be dismissed):

Street Address

City State Zip Code

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

4. 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

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 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. SIGNATURE of Complainant (or ATTORNEY) DATE

PART III ALLEGED DISCRIMINATORY ACTIONS

13. 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

14. If your complaint involves non-selection for a position, please complete the following:

Position Title Series Grade

Vacancy Announcement No. Date Learned of Non-

selection

15. Mark below ONLY the basis(es) you believe were relied on to take the actions described in #17.

□ Race (Specify) _________________________________ □ Mental Disability (Specify) ________________________

□ Color (State Complexion) __ _____________________ □ Physical Disability (Specify) _______________________

□ Religion (Specify) _______________________________ □ Equal Pay/Compensation (Specify) _________________

□ Sex (Gender, Sexual Harassment, Pregnancy, Sexual □ Genetic Information (Specify) _____________________

Orientation, or Gender Identity)___________________

_______________________________________________ □ Retaliation (Date(s) of prior EEO Activity) _________

______________________________________________

□ National Origin (Specify) _________________________ ______________________________________________

______________________________________________

□ Age (Date of Birth) ______________________________ ______________________________________________

16. Mark below ONLY the claim(s) you believe were relied on to take the actions described in #17.

	1. Appointment/Hire		14. Reassignment A. Denied B. Directed
	2. Assignment Of Duties		15. Reasonable Accommodation – Disability
	3. Awards		16. Reinstatement
	4. Conversion To Full-Time		17. Religious Accommodation
	5. Disciplinary Action A. Demotion B. Reprimand C. Suspension D. Termination E. Other		18. Retirement
	6. Duty Hours		19. Sex Stereotyping (LGBT- related discrimination only)
	7. Evaluation/Appraisal		20. Telework
	8. Examination/Test		21. Termination
	9. Harassment A. Non-Sexual B. Sexual C. Hostile Work Environment (non-sexual) D. Hostile Work Environment (sexual)		22. Terms/Conditions Of Employment
	10. Medical Examination		23. Time And Attendance
	11. Pay Including Overtime		24. Training
	12. Performance Evaluation/ Appraisal		25. Other
	13. Promotion/Non-Selection

17. (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 (gender, sexual harassment, pregnancy, sexual orientation, or gender identity), national origin, age (40 years or older), disability (mental and/or physical), genetic information, or in retaliation for your participation in the EEO complaint 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.)

18. What remedial or corrective action are you seeking?

PART IV EEO COUNSELOR CONTACT

19. When did the most recent discriminatory event occur?

_________________________________________________

Month Day Year

24. When did you receive your Notice of Right to File a Discrimination Complaint?

___________________________________________

Month Day Year

20. When did you first become aware of the alleged discrimination? _______________________________

Month Day Year

25. 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 a grievance or appeal, provide date filed, case number, and present status.

____________________________________________________

21. When did you contact an EEO Counselor?

_________________________________________________

Month Day Year

22. Did you discuss ALL actions raised in item 17 with an EEO Counselor? □ YES □ NO

(If no, explain on attached sheet)

23. Name and Telephone number of EEO Counselor

______________________________ ______________

Name Telephone No.