NRC Form 782 Compliant Form

PRIVACY ACT STATEMENT
NRC FORM 782
Complaint Form
Pursuant to 5 U.S.C. 552a(e)(3), enacted into law by Section 3 of the Privacy Act of 1974 (Public Law
93-579), the following statement is furnished to individuals who supply information to the U.S. Nuclear
Regulatory Commission (NRC) on NRC Form 782. This information is maintained in a system of records
designated as NRC-9 and described at 81 Federal Register 81327 (November 17, 2016), or the most
recent Federal Register publication of the NRC's Systems of Records Notices that is located in NRC's
Agencywide Documents Access and Management System (ADAMS).
1.

AUTHORITY: 5 U.S.C. 2301, 2302; 29 U.S.C. 206(d), as amended; 29 U.S.C. 633a, as amended;
29 U.S.C. 791; 42 U.S.C. 1981; 42 U.S.C. 2000e-16, as amended; 42 U.S.C. 5891; Executive Order
(E.O.) 11246 as amended; E.O. 11478 as amended; E.O. 12086, as amended by E.O. 12608, as
amended by E.O. 12608; E.O. 12106; E.O. 13166; 10 CFR part 4 and part 5; 29 CFR part 1614.

2.

PRINCIPAL PURPOSE(S): Filing complaints against NRC conducted and Federal financially
assisted programs and activities.

3.

ROUTINE USE(S): Information may be furnished to Equal Employment Opportunity Commission,
Office of Personnel Management, Merit Systems Protection Board, Department of Justice,
Department of Education, Department of Health and Human Services, Office of Management and
Budget, and Congress, under applicable requirements. Information may be disclosed in accordance
with any of the Routine Uses listed in the Prefatory Statement of General Routine Uses, including to
an appropriate Federal, State, local or Foreign agency in the event the information indicates a
violation or potential violation of law; in the course of an administrative or judicial proceeding; to an
appropriate Federal, State, local and foreign agency to the extent relevant and necessary for an NRC
decision about you or to the extent relevant and necessary for that agency's decision about you; in
the course of discovery under a protective order issued by a court of competent jurisdiction, and in
presenting evidence; to a Congressional office to respond to their inquiry made at your request; to
NRC-paid experts, consultants, and others under contract with the NRC, on a need-to-know basis; or
to appropriate persons and entities for purposes of response and remedial efforts in the event of a
suspected or confirmed breach of data from this system of records.

4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF
NOT PROVIDING INFORMATION: It is voluntary that you furnish the requested information;
however, failure to complete all appropriate portions of the form may lead to a dismissal or delay in
processing of your complaint because of insufficient data on which to evaluate the complaint.
5. SYSTEM MANAGER(S) AND ADDRESS: Associate Director, Civil Rights and Diversity Directorate
and Associate Director, Small Business Outreach and Compliance Directorate, Office of Small
Business and Civil Rights, U.S. Nuclear Regulatory Commission, Washington, D.C. 20555-0001.

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U. S. NUCLEAR REGULATORY COMMISSION
OFFICE OF SMALL BUSINESS AND CIVIL RIGHTS
OUTREACH AND COMPLIANCE COORDINATION PROGRAM

COMPLAINT FORM

APPROVED BY OMB: NO. 3150-0053

EXPIRES: (MM/DD/YYYY)

Estimated burden per response to comply with this mandatory collection request: 1 hour.
NRC requires this information to process allegations of discrimination. Send comments
regarding burden estimate to the Information Services Branch (T-2 F43), U.S. Nuclear
Regulatory Commission, Washington, DC 20555-0001, or by e-mail to Infocollects.
[email protected], and to the Desk Officer, Office of Information and Regulatory Affairs,
NEOB-10202, (3150-0053), Office of Management and Budget, Washington, DC 20503. If a
means used to impose an information collection does not display a currently valid OMB
control number, the NRC may not conduct or sponsor, and a person is not required to
respond to, the information collection.

This form is to be used to file complaints against NRC conducted and Federal financially assisted programs and activities that fall
under one of more of the following Federal legislative mandates: Title VI of the Civil Rights Act of 1964 (race, color, national origin); Title IX
of the Education Amendments of 1972 (sex); Section 504 of the Rehabilitation Act of 1973 (disability); Title IV of the Energy Reorganization
Act of 1974 (sex); The Age Discrimination Act of 1975 (Age); and Executive Orders related to providing equal and meaningful access to
programs for Limited English proficient persons; access and participation in NRC Federal Education and Training Programs; and
Environmental Justice. Under these provisions individuals in the protected classifications cannot be denied access, participation in, or
benefits from NRC conducted or Federal financially assisted programs and activities, or otherwise be subjected to discrimination.
(1) *Contact Person Name, Address, City, State & Zip Code, Telephone Number (Home), Telephone Number (Work), (Include area code):

(2) *Person(s) discriminated against, if different from person filing complaint: Address, City, State & Zip Code, Telephone Number (Home), Telephone
Number (Work)(Include area code):

(3) *Agency and department or program that discriminated against you: Agency name, Address, Name of Individual if known:

(4A) *Non-employment: Does your complaint concern discrimination in the
delivery of services or in other discrimination actions of the department or
agency in its treatment of you or others? If so, please indicate below the basis
on which you believe these discriminatory actions were taken.

(4B) *Employment: Does you complaint concern discrimination in
employment by the department or agency? If so, please indicate below the
base(s) on which you believe these discriminatory actions were taken.

Race

Sex

Age

Race

Sex

Age

Color

Disability

Sexual Orientation

Color

Disability

Sexual Orientation

National Origin

Religion

Status as a Parent

National Origin

Religion

Status as a Parent

(5) What is the most convenient method and time (telephone, email, other; time (6) *If we are not able to reach you directly, is there an alternate contact for
day/night, between the hours of
and
) for us to contact you about
information on the complaint?
this complaint?
I Can Be Reached
Between the Hours of:
Telephone Number
Email

:

AM
PM

and

:

AM

Yes

No

If yes, what is the name and telephone number?

PM
Name:
Telephone Number:

Other
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COMPLAINT FORM (Continued)
(7) *Your attorney information, if applicable:

(8) *To your best recollection, on what date(s) did the alleged discrimination
take place?
Earliest date of discrimination:
(MM/DD/YYYY)
Most recent date of discrimination:
(MM/DD/YYYY)

(9) *Complaints of discrimination must generally be filed within 180 days of the alleged discrimination. If the most recent date of discrimination, listed
above, is more than 180 days ago, you may request a waiver of the filing requirement. If you wish to request a waiver, please explain why you waited until
now to file your complaint.

(10) *Please explain as clearly as possible what happened, why you believe it happened, and how you were discriminated against. Indicate who was
involved. Be sure to include how other persons were treated differently from you. (Please use additional sheets, if necessary and attach a copy of
written materials pertaining to your case.)

(11) Civil Rights laws prohibit reprisal for filing complaints or opposing practices prohibited by these laws. If you have been subjected to retaliation or
intimidation (separate from the discrimination alleged in #10), please explain below including the actions you believe to be the basis for the reprisal.

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COMPLAINT FORM (Continued)
(12) *Please list below any persons (witnesses, fellow participants or employees, supervisors, or others), if known, for additional information regarding your
complaint.

No.

Name

Address

Telephone Number
(Include area code) and
Email Address

What information or documentation will the
individual be able to provide to support
your complaint?

1

2

3

4

5

(13) Do you have any other information that you think is relevant to our investigation of your allegations?

(14) What remedy are you seeking for the alleged discrimination?

(15) *Have you (or the person discriminated against) filed the same or any other complaints with NRC, another Federal agency, or the recipient company?
Yes

No If so, provide the complaint number.

What was the date of that
filing? (MM/DD/YYYY)

What is the name of the agency/department or program that the complaint was filed against? (Please provide the address, zip code and telephone number).

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COMPLAINT FORM (Continued)
Briefly state what the complaint was about?

What were the results?
Cause Finding

No Cause Finding

Other: (Explain)

(16) *Have you filed or do you intend to file a charge or complaint concerning the issues raised in this complaint with any of the following?
U. S. Department of Justice

Federal or State Court

U. S. Office of Health and Human Services

Your State or local Human Relations/Rights Commission

U. S. Equal Employment Opportunity Commission

Other Grievance or Complaint office

(17) *If you have already filed a complaint with an agency indicated in #16, please provide the following information (attach additional pages if necessary):
Name of Agency:

Date filed (MM/DD/YYYY):

Location of Agency/Court:

Name of Investigator:

Case or Docket Number:

Date of Trial/Hearing (MM/DD/YYYY):

Status of Case:

Comments:

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COMPLAINT FORM (Continued)
(18) If you know of any NRC funds or other assistance received by the program or department in which the alleged discrimination occurred, please provide
that information below:

(19) *REQUIRED SIGNATURE: We cannot accept a complaint, if it has not been signed. Please type in your signature and date below.
(SIGNATURE) Complainant's signature acknowledges and verifies

SIGNATURE DATE

(20) *REQUIRED SIGNATURE/CONSENT: Your signature below indicates your consent to disclosure of your name during the investigation processes. (If
you are filing this complaint for a person whom you allege has been discriminated against, we will need consent from that person).
(SIGNATURE) Complainant's signature acknowledges and verifies consent to release Complainant's name in the course
of any Investigation by NRC.

SIGNATURE DATE

For Questions, please call: (301) 415-7380
U. S. Nuclear Regulatory Commission
The Office of Small Business and Civil Rights
YOU MAY SAVE A COPY OF THIS COMPLETED FORM FOR YOUR RECORDS OR PRINT A COPY,
BEFORE YOU CLICK THE SUBMIT BUTTON.

TO SUBMIT YOUR REQUEST BY EMAIL, PRESS THE SUBMIT BUTTON BELOW.

NRC FORM 782

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Submit by Email

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