Form FCC Form 5621 FCC Form 5621 INFORMAL COMPLAINT of DISCRIMINATION

Approved by
0MB 3060-1237
Estimated Time Per
Response: 3.51 Hours

Federal Communications Commission
Office of Workplace Diversity

INITIAL CONTACT and/or COUNSELING SESSION
for INFORMAL COMPLAINT of DISCRIMINATION
2. ARE YOU A(N):

1. NAME (Last, First, Middle Initial)

D Employee
3a. HOME PHONE NO.

3b. WORK PHONE NO.

3c. MOBILE PHONE NO.

D

D

Former Employee

Applicant

3d. ADDRESS (Include City, State, and Zip Code)

3e. PRIMARY EMAIL

3f. SECONDARY EMAIL

4. ADDRESS OF YOUR CURRENT POSITION

5. TITLE AND GRADE OF YOUR CURRENT POSITION

6a. NAME OF INDIVIDUAL(S) YOU BELIEVE DISCRIMINATED AGAINST YOU

6b. DATE ON WHICH MOST RECENT ALLEGED DISCRIMINATION
OCCURRED

6c. SPECIFY BUREAU/OFFICE/DIVISION OF INDIVIDUAL(S) NAMED IN 6a.

7. REASON YOU BELIEVE YOU WERE DISCRIMINATED AGAINST (Check Below).

D
0

f. AGE

b. COLOR (State your Color)_

g. DISABILITY
Mental

____ _

0

c. RELIGION (State your Religion)_

D

d. SEX

0

e. NATIONAL ORIGIN (State your National Origin)

D

Female

D Male

_

D

D

__ _

Orientation

D

8. ISSUES IN THE COMPLAINT (CHECK APPROPRIATE BOX/BOXES)

D
D
D
D
D
D
D

D

_
a. RACE (State your Race)___ _ _ _

Accommodation (Medical)
Accommodation (Religious)
Assignment of Duties
Awards
Demotion
Detail
Disciplinary Warnings

D
D
D
D
D
D
D

Duty Hours
Evaluation/Appraisal
Harassment
Non-selection
Reassignment
Reinstatement
Removal

(Specify your Age) __

D Physical

h. GENETIC INFORMATION:

Gender Identity

D
D
D
D
D
D
D

□

Genetic Testing

D Family Medical History D Genetic Services
i. REPRISAL 0

Reprimand

D Other_

__
_
_

Retirement
Suspension
Telework
Termination
Terms/Conditions of Employment
Training

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INITIAL CONTACT and/or COUNSELING SESSION
for INFORMAL COMPLAINT of DISCRIMINATION
9. EXPLAIN SPECIFICALLY HOW YOU WERE DISCRIMINATED AGAINST (Explain how you were treated differently from other employees, former
employees or applicants, because of your race, color, religion, sex, national origin, age, mental or physical handicap, genetic information, or
reprisal.) (If your complaint involves more than one basis for your dissatisfaction, list and number each such allegation separately and furnish
specific, factual information in support of each allegation.) Use additional sheets if necessary.

10. WHAT SPECIFIC ACTION DO YOU WANT TAKEN TO RESOLVE YOUR COMPLAINT? (If more than one allegation is being made, state overall
corrective action desired and the specific corrective action desired for each separate allegation.)

11. THE EEO COUNSELOR DISCUSSED THE FOLLOWING SUBJECT AREAS IN THE COMPLAINT PROCESS AND/OR ALTERNATE DISPUTE
RESOLUTION (ADR) PROGRAM WITH THE EMPLOYEE/FORMER EMPLOYEE/APPLICANT AND/OR HANDOUTS WERE PROVIDED.

D
D
D

D g. 45-Day Requirement to Contact EEO Counselor
D h. Notify EEO Office of Attorney/Non-Attorney Representative
D i. Formal Stage Requirement of Attorney to Submit Billing Data
D j. Witness(es) Rights

a. The Role of the EEO Counselor
b. The Individual or Class Complaint Process
c. The Basis(es) to File a Complaint (Informal/Formal/Class)

0 d. The Right to File a Complaint

D
D

0 k. ADR Program

e. Avenues of Redress

D I. Informal Complaint Process

f. Rights and Responsibilities

12. THE EMPLOYEE/FORMER EMPLOYEE/APPLICANT ELECTS THE FOLLOWING OUTCOME:
a. Traditional Counseling

D Yes

b. ADR

No

O Yes

O

D No

c. Declined to Pursue Matter Under Title VII
d. Remain Anonymous

0Yes

D

D

Yes

0

No

No
14. DATE OF THIS COUNSELING SESSION
(Month, Day, Year)

13. SIGNATURE OF EMPLOYEE/FORMER EMPLOYEE/APPLICANT

DATE OF COUNSELING SESSION

NAME OF EEO COUNSELOR

SIGNATURE OF EEO COUNSELOR

Page 2

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FCC NOTICE REQUIRED BY THE PAPERWORK REDUCTION ACT
We have estimated that each response to this collection of information will take 3.51 hours. Our estimate includes the
time to read the instructions, look through existing records, gather and maintain the required data, and review the fom
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 (3060-1237), Washington, DC 20554. We will also accept your comments via the Internet if you send them
to [email protected]. Please DO NOT SEND COMPLETED APPLICATIONS 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 0MB control number or if
we fail to provide you with this notice. This collection has been assigned an 0MB control number of 3060-1237.
THE FOREGOING NOTICE IS REQUIRED BY THE PAPERWORK REDUCTION ACT OF 1995,
P.L. 104-13, OCTOBER 1, 1995, 44 U.S.C. 3507

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PRIVACY ACT STATEMENT:
1. Authority: 42 U.S.C. § 2000e-16; 29 CFR § 1614 et seq; 47 CFR § 0.81.
2. Purpose: These records are maintained for the purpose of counseling, investigating and adjudicating
complaints of employment discrimination brought by applicants and current and former federal employees against
federal employers.
3. Routine Uses: Information contained in this form is available to other individuals when necessary and
appropriate under 5 U.S.C. § 552a(b) of the Privacy Act, including: 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; 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; 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; 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; 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; 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; 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; to employees of
contractors engaged by an agency to carry out the agency's responsibilities under 29 CFR part 1614; to potential
witnesses as appropriate and necessary to perform the agency's functions under 29 CFR part 1614; to facilitate
statistical research, audit or investigative matters; and, to appropriate agencies, entities, and persons when the
FCC suspects or has confirmed that there has been a breach of information related to OWD.
4. Disclosure: Submission of this information is voluntary; however, failure to furnish this information will result
in the return of the complaint without action.

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