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

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Department of Transportation, Departmental Office of Civil Rights, S-34, 1200 New Jersey Avenue, SE., Washington, DC 20590

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, gender identity, or transgender status), 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 15calendar 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, Equal Employment Opportunity
Complaints and Investigations 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, gender
identity, or transgender status), 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:
a. to respond to a request 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;
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.
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

FOR OFFICE USE ONLY

DEPARTMENT OF TRANSPORTATION
INDIVIDUAL COMPLAINT OF EMPLOYMENT
DISCRIMINATION WITH THE DEPARTMENT OF
TRANSPORTATION

PART I

DEPARTMENT CASE NUMBER
FILING DATE

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

1. Name (Last, First, Middle Initial):
2. Telephone/Fax (Include Area Code):

Office and Staff Symbol:
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:
Street Address

□ Applicant

City
State
Zip Code
4. If you are a current or former employee of the
Federal government, list your most recent title, series,
and grade.

□ Probationary

□ Career/Career Conditional

□ Former Employee______________________________
Date Last Employed at Department
□ Retired
_____________________________
Date of Retirement
□ Other
_____________________________
Specify

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

PART II

Date

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.
10. Representative’s Employer (If Federal Agency):
9. Representative’s Mailing Address:

Firm/Organization

11. Representative’s Telephone/Fax (Include Area Code):

Street Address

_________________________________________________
Telephone:
Fax:

City

State

Zip Code

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.)

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

Office and Organizational Component
___________________________________________
Street Address

Position Title

City

Vacancy Announcement No.

State

Zip Code

Series

Grade

Date Learned of Nonselection

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
Orientation, Gender Identity, or Transgender Status)
_______________________________________________

□ Genetic Information (Specify) _____________________

□ National Origin (Specify) _________________________
□ Age (Date of Birth) ______________________________

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

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
3. Awards

15. Reasonable Accommodation
– Disability
16. Reinstatement

4. Conversion To Full-Time

17. Religious Accommodation

5. Disciplinary Action

18. Retirement

A.
B.
C.
D.
E.

Demotion
Reprimand
Suspension
Termination
Other

6. Duty Hours

19. Sex Stereotyping (LGBTrelated discrimination only)

7. Evaluation/Appraisal

20. Telework

8. Examination/Test

21. Termination

9. Harassment

22. Terms/Conditions Of
Employment

A. Non-Sexual
B. Sexual
C. Hostile Work Environment
(non-sexual)
D. Hostile Work Environment
(sexual)

10. Medical Examination

23. Time And Attendance

11. Pay Including Overtime

24. Training

12. Performance Evaluation/
Appraisal
13. Promotion/Non-Selection

25. Other

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, gender identity,
or transgender status), 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
20. When did you first become aware of the alleged
discrimination?
_______________________________
Month
Day
Year
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.

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

___________________________________________
Month
Day
Year
25. On this same matter, have you filed a grievance or appeal
under:
-

Negotiated Grievance procedures
Agency grievance procedure
MSPB appeal procedure

□ YES
□ YES
□ YES

□ NO
□ NO
□ NO

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

____________________________________________________