Form NRC Form 646 NRC Form 646 Formal Discrimination Complaint

NRC FORM 646

U.S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)

FORMAL DISCRIMINATION COMPLAINT

*Please read the information on Page 2 before completing this form.

Home Telephone Number

Full Name of Complainant

Home Address (Number, Street, City, State and Zip Code)

Are you a
bargaining
unit employee?

Work Telephone Number

E-mail Address

Title of Current Position

Yes

EXPIRES: (MM/DD/YYYY)

APPROVED BY OMB: NO. 3150-XXXX

Estimated burden per response to comply with this voluntary collection request: XX hour. NRC requires
this information to process allegations of discrimination. Send comments regarding burden estimate to
the FOIA, Library, and Information Collections Branch (T-6 A10M), U.S. Nuclear Regulatory Commission,
Washington, DC 20555-0001, or by e-mail to [email protected],and the OMB reviewer at:
OMB Office of Information and Regulatory Affairs, (3150-XXXX), Attn: Desk Officer for the Nuclear
Regulatory Commission, 725 17th Street NW, Washington, DC 20503; e-mail:
[email protected]. The NRC may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless the document requesting or requiring the collection displays
a currently valid OMB control number.

Office/Division/Branch

Series and Grade

No

Name of NRC Office(s) You Believe Discriminated Against You

Name of Involved Management Official with Position Title

Date On Which Most Recent Alleged Discrimination Occurred

Name of any witnesses with first hand knowledge of the alleged discrimination

PLEASE COMPLETE THIS SECTION IF YOU HAVE A REPRESENTATIVE
Name of Representative

Telephone Number

E-mail Address

Address (Number, Street, City, State and Zip Code)

PLEASE COMPLETE THIS SECTION IF YOU WORK FOR ANOTHER FEDERAL AGENCY (OTHER THAN NRC)
Name of Agency Where Currently Employed

Address (Number, Street, City, State and Zip Code)

I HAVE FILED A UNION NEGOTIATED GRIEVANCE ON THE ALLEGATION(S) IDENTIFIED HEREIN.
I HAVE FILED A MERIT SYSTEMS PROTECTION BOARD APPEAL ON THE ALLEGATION(S) IDENTIFIED HEREIN.
Date Filed (mm/dd/yyyy)

Current Status:

PLEASE CHECK THE BASIS(ES) AND FILL IN THE DATE(S), FOR YOUR COMPLAINT
Race (Specify)

Disability

Physical

Religion (Specify)
National Origin (Specify)
Sex (including gender identity,

sexual orientation and pregnancy)

Color (Specify)
Age (40+)(Specify)
Equal Pay (Specify)
NRC FORM 646 (MM-YYYY)

Mental

Prior EEO
Activity

Reprisal/
Retaliation

Opposing
policies/
practices
made
unlawful

Genetic Information
(Specify)
Other (Including marital
status, parental status,
political affiliation, military
service)

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U.S. NUCLEAR REGULATORY COMMISSION

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FORMAL DISCRIMINATION COMPLAINT (Continued)

Reprisal (continued) (In the box below, Identify earlier event(s) and/or opposed practice(s) - include dates)

PLEASE CHECK THE ISSUE(S) OF YOUR COMPLAINT.
Failure to Hire

Pay/Including Overtime
(Denial WIGI)

Assignment of Duties

Promotion/Non-Selection

Awards

Reassignment (Denied/
Direct Reassignment)

Conversion to Full Time

Reasonable
Accommodation

Disciplinary Action
(Specify)

Reinstatement

Duty Hours

Retirement (Including
Constructive Discharge)

Evaluation/Appraisal-PIRM

Sex - Stereotyping

Examination/Test

Termination

Sexual

Terms/Conditions
Employment

Non-Sexual

Time and Attendance

Harassment

Medical Examination

Training

Other (Specify in box on
right)
State specifically how you were treated differently from other employees or applicants because of the basis(es) you identified above. What harm,
if any, were you subjected to in your work situation as a result of that action. (See Notice of Right to File a Formal Discrimination Complaint
[NRTF]) (Please attach additional pages to this form if needed).

Briefly state the relief you are seeking

I PURSUED THE ALLEGATION(S) IDENTIFIED HEREIN THROUGH THE EEO COUNSELING / ADR PROCESS.
Name of EEO Counselor/ADR Representative

Date of Initial Contact (mm/dd/yyyy)

Date NRTF Issued (mm/dd/yyyy)

SIGNATURE
Signature and Date - Complainant or Attorney Representative

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U.S. NUCLEAR REGULATORY COMMISSION

FORMAL DISCRIMINATION COMPLAINT (Continued)
FILING A FORMAL DISCRIMINATION COMPLAINT

Read these following instructions carefully before you complete this form. Please complete all items on the NRC Form 646
complaint form.
GENERAL: Pursuant to the Equal Employment Opportunity Commission (EEOC) Title 29 Code of Federal Regulations (29
C.F.R.) §1614, NRC Form 646, Formal Discrimination Complaint, may be used by NRC employees, former employees and
applicants for employment who file a formal Equal Employment Opportunity (EEO) complaint of discrimination. This regulation
prohibits discrimination based on race, color, religion, sex (including sexual orientation, gender identity and expressions, and
pregnancy), national origin, age (40 years and over), physical or mental disability, genetic information (including family medical
history), marital status, parental status, political affiliation, military service, and/or reprisal for participating in the EEO process
or opposing unlawful discrimination.
You can obtain assistance from your EEO Counselor in filling out this form. Your EEO Counselor may also answer any
questions you may have about this form. Under the "Basis" section, you should specify the basis of your complaint: race,
color, religion, sex (including sexual orientation, gender identity and expressions, and pregnancy), national origin, age (month/
year of birth), physical or mental disability (specific information about your disability), genetic information (including family
medical history), marital status, parental status, political affiliation, military service, and/or reprisal for participating in the EEO
process or opposing unlawful discrimination. If you list "Reprisal," please state the nature of the prior EEO activity in which you
were engaged, i.e. did you file a prior EEO complaint? Use an additional sheet of paper, if necessary.
It is very important that you be precise as to the dates of all actions or events you are protesting. In addition, the claims listed
under the "Issues" section, must be limited to those claims discussed with the EEO Counselor (discussed within 45 calendar
days of occurrence of the event, or within 45 calendar days of the effective date, if a personnel action) or like or related claims.
If any of the claims listed under the "Issue" section were discussed with the EEO Counselor, but not within 45 calendar days of
their occurrence or of their effective date, you must explain why you waited more than 45 calendar days. If any of the claims
listed under the "Issues" section were not discussed with the EEO Counselor, please contact the Office of Small Business and
Civil Rights (SBCR), Civil Rights Program Manager and/or designee IMMEDIATELY. The requirement that you contact the
EEO Counselor about every claim listed under the "Issues" section will not be waived under any circumstances. Failure to do
so will only delay the processing of your complaint.
It is your responsibility to keep the Office of Small Business and Civil Right (SBCR) well informed of your current address. If
you move, immediately advise SBCR of your new address. In addition, you will receive all correspondence and
communications in connection with your complaint by email or electronic submission through Entellitrak.
REPRESENTATION: You may have a representative of your own choosing at all stages of the processing of your complaint.
No EEO Counselor, EEO Investigator or SBCR staff member may serve as a representative. (Your representative need not be
an attorney, but only an attorney representative may sign the complaint on your behalf.)
WHEN TO FILE: Your formal complaint must be filed within fifteen (15) calendar days of the date you received the "Notice of
Right to File a Formal Discrimination Complaint" (NRTF) from your EEO Counselor. If you do not meet this time limit, you must
explain why you waited more than fifteen (15) calendar days to file. These time limits may be extended under certain
circumstances; however, they will NOT be waived and your complaint will NOT be investigated unless you explain your
untimeliness and the explanation is acceptable in accordance with EEOC, 29 C.F.R. §1614(c).
WHERE TO FILE: The formal complaint must be signed and filed with NRC's Director, Office of Small Business and Civil
Rights (SBCR), by email or electronic submission through Entellitrak. Your complaint is deemed filed on the date received by
SBCR. If you fail to meet the fifteen (15) calendar day timeframe for filing your complaint, please include a written explanation
with your complaint.

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U.S. NUCLEAR REGULATORY COMMISSION

FORMAL DISCRIMINATION COMPLAINT (Continued)
PRIVACY ACT STATEMENT
NRC FORM 646, FORMAL DISCRIMINATION COMPLAINT

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 646. This information is maintained in a system of
records designated as EEOC/GOVT-1 Equal Employment Opportunity in the Federal Government Complaint and Appeal Records described at 71
Federal Register 24704 (April 26, 2006).
1. AUTHORITY: 42 U.S.C. 2000e-16(b) and (c); 29 U.S.C. 204(f) and 206(d); 29 U.S.C. 633(a); 29 U.S.C. 791; Reorg. Plan No. 1 of 1978, 43 FR
19,607 (May 9, 1978); Exec. Order No. 12106, 44 FR 1053 (Jan. 3, 1979).
2. PRINCIPAL PURPOSE(S): Formal filing of complaint of discrimination based on race, color, national origin, religion, sex (including gender identity,
sexual orientation and pregnancy), age, disability, or reprisal.
3. ROUTINE USE(S): In addition to the other types of disclosures permitted under subsection of the Privacy Act, information from this system of
records may be disclosed;
a. To disclose pertinent information to the appropriate federal, state, or local agency responsible for investigating, prosecuting, enforcing, or
implementing a statute, rule, regulation, or order, where the disclosing agency becomes aware of an indication of a violation or potential violation
of civil or criminal law or regulation.
b. To disclose information to another federal agency, to a court, or to a party in litigation before a court or in an administrative proceeding being
conducted by a federal agency when the government is a party to the judicial or administrative proceeding.
c. To provide information to a congressional office from the record of an individual in response to an inquiry from that congressional office made at
the request of that individual.
d. To disclose to an authorized appeal grievance examiner, formal complaints examiner, administrative judge, equal employment opportunity
investigator, arbitrator or other duly authorized official engaged in investigation or settlement of a grievance, complaint or appeal filed by an
employee.
e. To disclose, in response to a request for discovery or for appearance of a witness, information that is relevant to the subject matter involved in a
pending judicial or administrative proceeding.
f. To disclose information to officials of state or local bar associations or disciplinary boards or committees when they are investigating complaints
against attorneys in connection with their representation of a party before EEOC.
g. To disclose to a Federal agency in the executive, legislative, or judicial branch of government, in response to its request information in
connection with the hiring of an employee, the issuance of a security clearance, the conducting of a security or suitability investigation of an
individual, the classifying of jobs, or the lawful statutory, administrative, or investigative purpose of the agency to the extent that the information is
relevant and necessary to the requesting agency's decision.
h. To disclose information to employees of contractors engaged by an agency to carry out the agency's responsibilities under 29 CFR part 1614.
i. To disclose information to potential witnesses as appropriate and necessary to perform the agency's functions under 29 CFR part 1614. For
additional details on these routine uses, please see the EEOC/GOVT-1 system notice.
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 delay in processing
your complaint because of insufficient data on which to determine if complaint is acceptable.
5. SYSTEM MANAGER(S) AND ADDRESS: Senior Level Assistant for Policy and Programs, Office of Small Business and Civil, U.S. Nuclear
Regulatory Commission, Washington, D.C. 20555-0001.

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