Form NRC Form 655 NRC Form 655 EEO Counselor's Report

NRC FORM 655
(MM-YYYY)

U.S. NUCLEAR REGULATORY COMMISSION

EEO COUNSELOR'S REPORT
29 CFR SECTION 1614.105(C)

APPROVED BY OMB: NO. 3150-XXXX

EXPIRES: (MM/DD/YYYY)

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.

AGGRIEVED PERSON
Name and Title

Series and Grade

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

Ofc/Div/Brnch Assigned

Work Telephone

Home Telephone

Ofc/Div/Brnch Discrimination Occurred

COMPLETE THIS SECTION IF AGGRIEVED PERSON HAS A REPRESENTATIVE
Name of Representative

Telephone Number

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

Is Representative an Attorney?
No

Yes

CHRONOLOGY OF EEO COUNSELING EFFORT (As applicable)
Date of Initial Contact to Request EEO Counseling: (MM/DD/YYYY)
Date Initial Interview Conducted: (MM/DD/YYYY)
Date of Alleged Discriminatory Incident or Event: (MM/DD/YYYY)
45th Day after Event: (MM/DD/YYYY)
Reason for delayed contact beyond 45 days, if applicable:
Date Aggrieved Signed Rights and Responsibility Package: (MM/DD/YYYY)
Date of Extension Agreement (if any): (MM/DD/YYYY) If an Extension is agreed to, note the not-to-exceed (date):
Date of Election to use ADR: (MM/DD/YYYY)
Date Notified that ADR Completed: (MM/DD/YYYY)
Date of Final Interview: (MM/DD/YYYY)
Date Notice of Right to File a Discrimination Complaint Issued: (MM/DD/YYYY)
Date EEO Counselor's Report Submitted: (MM/DD/YYYY)

BASIS(ES) FOR ALLEGED DISCRIMINATION (Check all that apply)
Race (Specify)

Color (Specify)

Religion (Specify)

Age (40+) (Specify)

National Origin
(Specify)

Disability

Sex (Including gender

identity, sexual orientation
and pregnancy)

Equal Pay
(Specify)
Other (Including marital
status, parental status,
political affiliation,
military service)
NRC FORM 655 (MM-YYYY)

Mental
Physical

Genetic Information
(Specify)
Prior EEO
Activity
Reprisal/ Opposing
Retaliation policies/
practices
made
unlawful

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NRC FORM 655
(MM-YYYY)

EEO COUNSELOR'S REPORT
29 CFR SECTION 1614.105(C) (Continued)
ISSUE(S) OF ALLEGED DISCRIMINATION (Check all that apply)

Appointment/Hire

Promotion/Non-Selection

Assignment of Duties

Reassignment
(Denied/Directed Reassignment)

Awards

Reasonable Accommodation

Conversion to Full Time

Reinstatement

Disciplinary Action - (Specify)
Duty Hours

Retirement (Including Constructive
Discharge)

Evaluation/Appraisal - PIRM

Sex - Stereotyping

Examination/Test

Termination

Harassment

Sexual

Terms/Conditions Employment

Non-Sexual

Time and Attendance

Medical Examination

Training

Pay/Including Overtime (Denial WIGI)

Other (Specify in box on right)

AGGRIEVED ASSERTS BASIS(ES) NOT COVERED BY EEO REGULATIONS
Did the Aggrieved Assert:

If yes, the following advisement must be given:

Reprisal for making whistle-blower disclosures?

Reprisal for whistle-blowing disclosures is not within the purview or jurisdiction of Federal EEO complaint
process. Specific protection is afforded under the Whistle Blower Protection Act through the Office of
Special Counsel at the MSPB.

Reprisal for filing a negotiated grievance?

Obtain a copy of the grievance from the Aggrieved.

Any other Non-EEO Issue? (Describe in box)

AGGRIEVED WAS ADVISED OF POSSIBLE ELECTIONS (Where applicable)
1.

Aggrieved was advised of his/her right to anonymity during the pre-complaint stage.

2.

If the matter in dispute is appealable to the MSPB, was the aggrieved person specifically
advised of the right to file a Mixed-Case Complaint of a Mixed-Case Appeal, But not both?

3.

4.

5.

Request Anonymity
Waives Right to Anonymity
Not MSPB Matter
Aggrieved Advised
Aggrieved Not Covered

If the aggrieved person is covered by a collective bargaining agreement, was he/she specifically
advised of the right to file either a complaint or a grievance, but not both?

Aggrieved Advised

If the aggrieved person is alleging age discrimination, was he/she specifically advised of the right to bypass the agency complaint process and file a civil action after 30 days notice to the EEOC's Office of
Federal Operations?

Not an ADEA Complaint
Aggrieved Advised
Aggrieved did not Opt ADR

The Aggrieved Person was fully informed about the availability of ADR?

ADR Opted

AGGRIEVED SELECTS ADR
Date the Aggrieved elected to pursue mediation: (MM/DD/YYYY)
Date referred to ADR Coordinator: (MM/DD/YYYY)
ADR accepted by management
Date:
ADR declined by management
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EEO COUNSELOR'S REPORT
29 CFR SECTION 1614.105(C) (Continued)
AGGRIEVED SELECTS ADR (Continued)
Date for pre-complaint counseling to conclude [enter date 90 days from date of Initial Interview]:
Date ADR was completed and the outcome (Check One):
Settled during mediation
Not resolved during mediation.

Date:

Not appropriate for mediation.
Date NRTF Issued/Signed (Check One):
ADR has not been completed: 90 Days have elapsed.
ADR has been completed: the matter has not settled.

Date:

RELIEF REQUESTED

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EEO COUNSELOR'S REPORT
29 CFR SECTION 1614.105(C) (Continued)
COUNSELOR'S INQUIRY
INITIAL INTERVIEW WITH AGGRIEVED PERSON (AP)
Name and Title

NRC FORM 655 (MM-YYYY)

Work Telephone

Date (MM/DD/YYYY)

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EEO COUNSELOR'S REPORT
29 CFR SECTION 1614.105(C) (Continued)
COUNSELOR'S INQUIRY

DOCUMENTS REVIEWED (INCLUDE SOURCE OF DOCUMENTS):
LIST DOCUMENT(S) AND DATE(S)

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EEO COUNSELOR'S REPORT
29 CFR SECTION 1614.105(C) (Continued)
SUMMARY OF INTERVIEWS

PERSONAL CONTACTS:
Name and Title

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Work Telephone

Date (MM/DD/YYYY)

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(MM-YYYY)

EEO COUNSELOR'S REPORT
29 CFR SECTION 1614.105(C) (Continued)
SUMMARY OF INFORMAL RESOLUTION ATTEMPT/FINAL INTERVIEW
AGGRIEVED PERSON (AP):
Name and Title

Work Telephone

Date (MM/DD/YYYY)

SIGNATURES
Typed or Printed Name of EEO Counselor

Work Telephone

Signature and Date - EEO Counselor

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U.S. NUCLEAR REGULATORY COMMISSION

EEO COUNSELOR'S REPORT
29 CFR SECTION 1614.105(C) (Continued)
PRIVACY ACT STATEMENT
NRC FORM 655, EEO COUNSELOR'S REPORT

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
655. 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): To document the complainant's statements in reference to their 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 request for counseling.
5. NRC CONTACT AND ADDRESS INFORMATION: 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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