Form TD F 62-03.4 TD F 62-03.4 Agreement to Extend Counseling to Participate in Mediati

Privacy Act Statement
AUTHORITY: 29 U.S.C. § 206(d); 29 U.S.C. § 791; 42 U.S.C. § 2000e; 42 U.S.C. § 2000ff-(2);
29 U.S.C. § 633a; 5 U.S.C. § 1303-1304; 5 CFR § 5.2-5.3; 29 CFR § 1614.105, .107; Executive
Order 11478, as amended; and Executive Order 13152 and Management Directive 110 (August
2015).
PRINCIPAL PURPOSE(S): This information is being collected for the sole purpose to record a
pre-complaint allegation of employment discrimination with the Department of the Treasury on
the grounds of race, color, religion, sex (including pregnancy, sexual orientation and gender
identity), national origin, age, disability, protected genetic information, parental status, or reprisal.
An employee or applicant must participate in pre-complaint EEO counseling to informally resolve
the allegation(s) per § 1614.105, prior to filing a formal EEO complaint of discrimination.
Information provided on this form will be used by the aggrieved to voluntarily participate in
mediation under the EEO Alternative Dispute Resolution (ADR) process, which automatically
extends the process an additional 60 calendar days, not to exceed a total of 90 days. The
information captured on this form will be used by the Department of the Treasury to record the
decision of the aggrieved to extend counseling to participate in the ADR process.
ROUTINE USE(S): The information on this form may be disclosed as generally permitted under
5 U.S.C. §552a(b) of the Privacy Act of 1974, as amended. This includes using this information
as necessary and authorized by the routine uses published in Treasury .013--Department of the
Treasury Civil Rights Complaints and Compliance Review Files – 81 FR 78266 (Nov. 7, 2016).
PAPERWORK REDUCTION ACT STATEMENT: In accordance with the Paperwork Reduction
Act of 1995, the Department of the Treasury may not conduct or sponsor, and the respondent is
not required to respond to this collection of information unless it displays a valid OMB Control
Number. The valid OMB Control Number for this information collection is 1505-0262. The
collection of this information is voluntary. However, the information is necessary to determine if
your complaint of employment discrimination is acceptable for further processing in accordance
with EEOC, 29 C.F.R. §1614. The time required to complete this information collection is
estimated to average 5 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing the
form. Send comments regarding this burden estimate or any other aspects of this collection,
including suggestions for reducing this burden, to Department of the Treasury, Office of Civil
Rights and EEO, 1500 Pennsylvania Avenue, N.W., Washington, DC 20220.

TD F 62-03.4
Revised 2/2017

S p a c e le f t
b la n k f o r
b u re a u ’s s e a l

OMB No. 1505-0262
Expiration Date: 06/30/2025

Department of the Treasury
Space left blank for bureau's name
Name of the Aggrieved: ___________________________

__________________
______________________________________________________
Pre-Complaint Number:

Agreement to Extend Counseling to Participate in Mediation
This is an agreement, by the participants signing below, to participate voluntarily in mediation under the EEO Alternative
Dispute Resolution (ADR) process, which automatically extends the process an additional 60 calendar days, not to
exceed a total of 90 days. The allegations raised in the Equal Employment Opportunity (EEO) pre-complaint process
will be, unless specifically excluded in writing, those submitted for attempted resolution by mediation. All parties
understand that nothing said or done during attempts to resolve the matter through mediation can be made the subject
of an EEO complaint or any proceeding.
Release of Information
The EEO Counseling Report will be given to the mediator or co-mediators, if requested and available.
Participation is Voluntary
The participants understand that participation is voluntary and any participant may terminate the mediation at any time.
Mediator has No Decision Authority
The participants further understand that the mediator or co-mediators have no authority to make decisions on issues
raised nor act as an advocate or representative for either party. The aggrieved may consult with a designated
representative. If resolution occurs as a result of mediation, the resolution agreement will be prepared in conformance
with the established procedures.
Mediator is Not a Witness
Each participant agrees not to subpoena or request as a witness any mediator or request to use as evidence any
materials prepared by the mediator for use during mediation with the exception of any signed resolution agreement. In
no event will the mediator voluntarily serve as a witness or testify in any proceeding.
End of Mediation
The mediation will be concluded when:
a. a resolution agreement is signed by the management and resolution officials and the aggrieved and his/her
representative;
b. the aggrieved withdraws the EEO pre-complaint in writing;
c. it is determined that the participants are unable to resolve the issues at hand and mediation is terminated; or
d. the mediation can be canceled by the mediator for any reason during the mediation session.
Unresolved Issues
At the end of the mediation period, if no resolution has been achieved, the aggrieved will be given the Notice of Right
to File a Formal EEO Complaint. The notice of right to file a formal complaint will be issued to the
aggrieved by the EEO Counselor, who will review the statutory requirement to proceed with the filing of the
formal complaint.
Confidentiality
The participants understand and stipulate that the mediation sessions are confidential and no participant shall disclose
any of the discussions except for the limited purpose of implementation and enforcement of the agreement. In
addition, nothing said or done during attempts to resolve the matter through mediation can be made the subject of an
EEO complaint.

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If the participants reach a resolution, the agreement shall be reduced to writing and, when signed, shall be binding upon
all participants to the agreement.

______________________________________________________
______________________________________________________
Signature of Aggrieved

________________________
Date

______________________________________________________
Signature of EEO Counselor

________________________
Date

_____________________________________________________
Signature of Aggrieved Person's Representative

________________________
Date

TD F 62-03.4
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