Form FCC Form 5632 FCC Form 5632 FCC Anti-Harassment Intake Form

OMB Control No.3060-XXXX

Estimated Time Per Response: 3 hrs.

Federal _{Communications Commission} ANTI-HARASSMENT INTAKE FORM

Washington, DC 20554 (To be completed by the employee)

1. INFORMATION

a. FULL NAME

b. EMAIL ADDRESS

2. EMPLOYMENT INFORMATION

a. TITLE

d. SERIES/GRADE

b. IF CURRENTLY EMPLOYED AT THE FCC, INDICATE YOUR

JOB STATUS

FCC EMPLOYEE

CONTRACTOR

OTHER (Explain)

e. OFFICE ADDRESS (Street, City, State, ZIP Code)

c. ORGANIZATION

f. TELEPHONE NUMBER

3. WHO IS THE PERSON(S) ENGAGING IN THE HARASSMENT YOU ARE REPORTING?

NAME

TITLE/OFFICE

5. WHEN DID THIS CONDUCT OCCUR? HOW OFTEN DID IT OCCUR? AND IS IT STILL OCCURRING? (If more space is needed, please attach an additional page.)
6. ARE THERE ANY WITNESSES TO THE HARASSMENT? (If so, please list their names and titles.)

4. EXPLAIN WHY YOU BELIEVE YOU WERE HARASSED. (If more space is needed, please attach an additional page.)

	7. WHAT CORRECTIVE ACTION ARE YOU SEEKING?
8. CHECK BASIS(ES) YOU BELIEVE CAUSED THE HARASSMENT
a. RACE			(Specify)	i. DISABILITY (Specify)
				j. AGE
b. COLOR			(Specify)
				k. REPRISAL
c. RELIGION			(Specify)
d. NATIONAL ORIGIN			(Specify)
e. SEX			(Specify)
f. MARITAL STATUS			(Specify)
g. POLITICAL AFFILIATION			(Specify)
h. PARENTAL STATUS			(Specify)
THE STATEMENTS CONTAINED IN THIS INTAKE FORM ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE, INFORMATION AND BELIEF. ADDITIONALLY, I UNDERSTAND THAT THIS PROCESS IS COMPLETELY SEPARATE FROM THE EEO PROCESS AND IF I INTEND TO FILE AN EEO COMPLAINT I MUST DO SO WITHIN 45 DAYS OF THE ALLEGED HARASSMENT.
SIGNATURE					DATE
PRIVACY ACT STATEMENT Authority: The Civil Rights Act of 1964 § 7, as amended, 42 U.S.C. § 2000e; Age Discrimination in Employment Act of 1967 (ADEA), 29 U.S.C. §§ 621 634; Americans with Disabilities Act of 1990 (ADA), as amended, 42 U.S.C. §§ 12101-12213; Rehabilitation Act of 1973, as amended, 29. U.S.C. § 501 et seq. Purpose: The principal purpose for collecting this information is to permit the Federal Communications Commission (FCC), through its Human Resources Management and Anti-Harassment Policy, to assist the claimants referenced herein in determining whether harassing conduct has occurred and what immediate corrective actions must be taken. Additionally, the FCC collects and maintains this information to process, resolve, record and track requests for anti-harassment services, by FCC managers, supervisors and employees. Information collected in connection with a request for anti-harassment services is confidential and may be shared with Agency officials or Agency contractors only when those other individuals need to know the information to make determinations resulting from an anti-harassment request or to assist Human Resources Management in making such a determination. Routine Uses: The records and information in the records may be used pursuant to the Routine Uses for the system found in the System of Records Notice EEOC/GOVT1, Equal Employment Opportunity (EEO) in the Federal Government Complaint and Appeal Records, 81 Fed. Reg. 81,116 (Nov. 17, 2016). Effect of Disclosure: The provision of information is voluntary; however, if you do not provide this information, the FCC may not provide you with anti-harassment services, and you may not receive important information. PAPERWORK REDUCTION ACT STATEMENT We have estimated that each response to this collection of information will take three hours. Our estimate includes the time to read the instructions, look through existing records, gather and maintain the required data, and actually complete and review the form or response. If you have any comments on this estimate, or on how we can improve the collection and reduce the burden it causes you, please write the Federal Communications Commission, AMD-PERM, Paperwork Reduction Project (3060-XXXX), Washington, DC 20554. We will also accept your comments via the Internet if you send them to [email protected]. Please DO NOT SEND COMPLETED REQUESTS TO THIS ADDRESS. Remember - you are not required to respond to a collection of information sponsored by the Federal government, and the government may not conduct or sponsor this collection, unless it displays a currently valid OMB control number or if we fail to provide you with this notice. This collection has been assigned an OMB control number of 3060-XXXX.

FCC-5632, Effective Date: 04/2018