Form TD F 62-03.11 TD F 62-03.11 ADR Election Form

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. The information captured on this form will be used by the Department of the
Treasury to record the election of the aggrieved to continue with the pre-complaint EEO
counseling process or to voluntarily participate in mediation under the EEO Alternative
Dispute Resolution (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 system of notice records notice
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 62-03.11
Revised 2/2017

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

Space left
blank
for bureau
seal

Department of the Treasury
Space Left Blank for Bureau Name
Name of the Aggrieved: ______________________________
Pre-Complaint Number: ______________________________

ALTERNATE DISPUTE RESOLUTION
The Alternative Dispute Resolution (ADR) process was fully explained to the aggrieved
person. The EEO Counselor provided the person with the opportunity to elect
between EEO Counseling and ADR. A copy of the bureau's ADR Program booklet
was provided to the aggrieved person.

__________________________________
Signature of EEO Counselor

_______________
Date

I elect mediation instead of EEO Counseling

I do not want mediation and wish to continue with EEO Counseling.

___________________________________
Signature of Aggrieved

TD F 62-03.11
Revised 2/2017

_______________
Date