Form TD F 62-03.1 TD F 62-03.1 EEO Informal Report of Counseling

OMB No. 1505-XXXX

INSTRUCTIONS FOR COMPLETING EEO INFORMAL REPORT OF EEO COUNSELING FORM

The EEO Counselor is responsible for completing the EEO Counseling Report. Items 1
through 21 of the form must be completed and uploaded into iComplaints within ten (10)
business days of the issuance of the Notice of Right to File. If you cannot obtain requested
information, please make a note of this and attach it to this form. If the employee/applicant
files a formal EEO discrimination complaint, you should forward to the aggrieved, and/or
aggrieved's representative, a copy of this report, plus appropriate attachments. Note: The job
application of another person, for example, is not appropriately included among attachments
sent to the aggrieved.
The EEO Counselor is not the custodian of the EEO Counselor report system of records
under the Privacy Act. Therefore, you must not for any reason or purpose keep a copy of the
Report, or any enclosures, attachments, or notes, after you have been notified of the filing of
an EEO complaint and have uploaded the originals into the Department's electronic tracking
system, or after a period of 45 calendar days from the date of final interview. You should
conduct the final interview within 30 calendar days after the date of initial contact with the
employee/applicant, unless an extension has been granted. If an extension has been
granted, EEO counseling must be completed and the Notice of Right to File a Formal EEO
Discrimination Complaint must be issued within 90 calendar days of the date of initial contact.
A COPY OF THE EEO COUNSELING REPORT PLUS APPROPRIATE ATTACHMENTS
MUST BE DELIVERED TO AGGRIEVED, OR AGGRIEVED'S REPRESENTATIVE,
WHEN THE COMPLAINT IS FILED.

TD F 62-03.1
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Privacy Act Statement
AUTHORITY: 29 U.S.C. § 206(d); 29 U.S.C. § 791; 42 U.S.C. § 2000e; 42 U.S.C. § 2000ff-(2);
29 U.S.C. § 633a; 5 U.S.C. § 1303-1304; 5 CFR § 5.2-5.3; 29 CFR § 1614.105, .107; Executive
Order 11478, as amended; and Executive Order 13152 and Management Directive 110 (August
2015).
PRINCIPAL PURPOSE(S): This information is being collected for the sole purpose to record a
pre-complaint allegation of employment discrimination with the Department of the Treasury on
the grounds of race, color, religion, sex (including pregnancy, sexual orientation and gender
identity), national origin, age, disability, protected genetic information, parental status, or
retaliation. An employee or applicant must participate in pre-complaint EEO counseling to
informally resolve the allegation(s) per § 1614.105, prior to filing a formal EEO complaint of
discrimination. Information provided on this form will be used by the employee/applicant at the
end of pre-complaint counseling to determine if she/he wants to pursue filing a formal EEO
complaint of discrimination against the Department of the Treasury. The information captured on
this form will be reviewed by the Department of the Treasury when a formal EEO discrimination
complaint is filed to determine whether allegations are within the purview of 29 CFR Part 1614, or
the Executive Orders identified above.
ROUTINE USE(S): The information on this form may be disclosed as generally permitted under
5 U.S.C. §552a(b) of the Privacy Act of 1974, as amended. This includes using this information
as necessary and authorized by the routine uses published in Treasury 013--Department of the
Treasury Civil Rights Complaints and Compliance Review Files system of records notice (FR Doc
No: 2011-22977).
PAPERWORK REDUCTION ACT STATEMENT: In accordance with the Paperwork Reduction
Act of 1995, The Department of the Treasury may not conduct or sponsor, and the respondent is
not required to respond to this collection of information unless it displays a valid OMB Control
Number. The valid OMB Control Number for this information collection is 1505-XXXX. The
collection of this information is voluntary. However, the information is necessary to determine if
your complaint of employment discrimination is acceptable for further processing in accordance
with EEOC, 29 C.F.R. §1614. The time required to complete this information collection is
estimated to average 1 hour per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing the
form. Send comments regarding this burden estimate or any other aspects of this collection,
including suggestions for reducing this burden, to Department of the Treasury, Office of Civil
Rights and Diversity, 1500 Pennsylvania Avenue, N.W., Washington, DC 20220.
TD F 62-03.1
Revised 2/2017

DEPARTMENT OF THE TREASURY
EQUAL EMPLOYMENT OPPORTUNITY INFORMAL REPORT OF COUNSELING 2
Name of EEO Counselor Filing Report:

Bureau name:

Name of EEO Counselor Filing Report:

EEO Counselor’s E-mail Address:

Informal Pre-Complaint Number:

1. Formal Complaint Processing Office:

2. EEO Officer:

3. Resolution Program Manager:

Office of Civil Rights and Diversity
Department of the Treasury
1500 Pennsylvania Avenue, NW
Washington, DC 20220

4. Date Counseling First Sought:

5. Date of Initial Interview:

6. Employee or Applicant:

7. Matter Causing Complaint or Issue:

Name:

Appointment/Hire

Pay Including Overtime

Assignment of Duties

Promotion/ Non-Selection

Awards

Reasonable
Accommodation

Class Complaint

(Disability)

Conversion to Full-time

Reasonable
Accommodation

Disciplinary Action: Demotion

(Religious)

Disciplinary Action: Removal

Reassignment (Denied)

Disciplinary Action: Reprimand

Reassignment (Directed)

Disciplinary Action: Suspension

Reinstatement

Race:

Duty Hours

Retirement

Color:

Equal Pay

Termination

National
Origin:

Examination/Test

Terms/Conditions of
Employment

Religion:

Evaluation/Appraisal

Time and Attendance

Harassment (Non-sexual)

Training

Harassment (Sexual)

Working Conditions

Medical Examination

Other

Title:
Grade & Series:
Office:
Mailing
Address:
Telephone No.:
8. Basis or Type of Discrimination:
Age:

Disability:

Month/Year:

[

] Mental

[

]

Physical

Participation _________________

Retaliation/Reprisal
[

] Opposition ___________________

Protected Genetic Information
Sex
(Gender):

Male

(Please describat the
space provided at the
bottom of this page)

Female

Pregnancy
Sexual Orientation
Gender Identity

Parental
Status

With respect to an individual who is under the age of 18 or who is 18 or older but is incapable of self-care because of a physical or mental disability, is: a biological
parent, an adoptive parent, a foster parent, a stepparent, a custodian of a legal ward, in loco parentis over such individual or actively seeking legal custody or adoption
of such an individual.

(Other: Please describe below) Maximum characters and spaces is 1064. If additional space is required, please continue on
a separate sheet of paper and attach it to this form.

9. Date Aggrieved signed the Notice of Rights and Responsibilities:

TD F 62-03.1
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10. An EEO Counselor cannot reveal the identity of a person who has come for EEO counseling, except when authorized to do so by the
person counseled.
Is Aggrieved willing to have his/her name revealed during the EEO counseling stage? If
answer is “Yes,” Aggrieved must consent on the Rights and Responsibilities sheet
11a. Date the Alleged
Discrimination Occurred:
11b. Organization Where Alleged Discrimination Occurred:

YES

NO

12a. Date Aggrieved became
aware of alleged
discrimination:
12.b Explain if the date in 11a is different than the date in 12a.

13. If complaint appears to be untimely, what explanation is offered to explain why EEO Counselor was not contacted within 45 days?

14. Report of EEO Counseling and information developed during inquiry (Identify the source of each fact; attach relevant documents provided
by employee/applicant, management officials involved, other witnesses, personnel, etc., or those obtained by the Counselor.) Attach separate
page(s) if more space is required.
The maximum number of characters and spaces allowed is 1482. If additional space is needed, continue on a separate sheet
of paper and attach it to this form.

15. Remedial Action Desired by Aggrieved:

TD F 62-03.1
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16.

Has Aggrieved raised the same matter under another procedure? If "yes", please attach supporting documentation.
•

On the same matter has Aggrieved filed a grievance under a negotiated grievance procedure?

YES

NO

•

On the same matter has Aggrieved filed a grievance under the Agency grievance system?

YES

NO

•

Has Aggrieved appealed to the Merit Systems Protection Board?

YES

NO

YES

NO

If a grievance or appeal has been filed, what is its status and grievance number?
17. Does Aggrieved elect to have a representative?
YES

NO

If Yes, please provide Representative’s contact information:

Name:
Telephone Number:
Address:
Email Address:

18. Was the Aggrieved offered ADR?
If ‘NO,’ indicate reason ADR was not offered;

Did Aggrieved Elect to Participate in ADR?

YES

NO

Date Request for ADR was Submitted:
Date Mediation Occurred

19. EEO Counseling Inquiry Contacts (If additional space is required, please continue on a separate sheet of paper labeled "Contacts" and attach
it to this form.)
Date of
Contact

Name

Position Title

Contact Information - Work email address/tele number

20. Responding Manager Official(s):

20b. Date
Interviewed:

20c. Management's Response: (If additional space is required, please continue on a separate sheet of paper labeled "Management's Response",
include the responding official's name and attach it to this form.)

21. Date of Final Interview with Aggrieved/Notice of Right to File EEO Discrimination Complaint Issued:
Signature of EEO Counselor
Date Signed

TD F 62-03.1
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