Form FCC Form 5621 FCC Form 5621 INFORMAL COMPLAINT of DISCRIMINATION

Approved by
Federal Communications Commission
OMB 3060-1237
Office of Workplace Diversity
Estimated Time Per
Response:
3.51 Hours
draft
INITIAL CONTACT and/or COUNSELING SESSION
for INFORMAL COMPLAINT of DISCRIMINATION
PRIVACY ACT STATEMENT: 1. AUTHORITY - The authority to collect this information is derived from 42 U.S.C. § 2000e-16;
29 C.F.R. §§1614 .106, 1614.108. 2. PURPOSE AND USE - This information will be used to document the issues and
allegations of a complaint of discriminaton based on race, color, sex (including sexual harassment), religion, national origin
age, disability (physical or mental), genetic information, or reprisal. The signed statement will serve as the record necessary
to initiate an investigation and will become part of the complaint file during the investigation or hearing, if any; adjudication
and appeal, if one, to the Equal Employment Opportunity Commission . 3. EFFECTS OF NON - DISCLOSURE - Submission
of this information is MANDATORY. Failure to furnish this information will result in the return of the complaint without action.
1. NAME (Last, First, Middle Initial)

2. ARE YOU A(N):
Employee

3a. HOME PHONE NO.

3c. MOBILE PHONE NO.

3b. WORK PHONE NO.

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).
a. RACE (State your Race)

f. AGE

_

b. COLOR (State your Color)

(Specify your Age)

g. DISABILITY

_

Mental
c. RELIGION (State your Religion)

_

Physical

h. GENETIC INFORMATION:0
Family Medical History

d. SEX

Female

Male

Orientation

Gender Identity

Genetic Testing
Genetic Services

i. REPRISAL

e. NATIONAL ORIGIN (State your National Origin)
8. ISSUES IN THE COMPLAINT (CHECK APPROPRIATE BOX/BOXES)
Accommodation (Medical)
Accommodation (Religious)
Assignment of Duties
Awards
Demotion

Reinstatement

Duty Hours

Removal

Evaluation/Appraisal

Reprimand

Harassment
Non-sexual

Retirement

Sexual

Detail

Non-selection

Disciplinary Warnings

Reassignment

Suspension

Terms/Conditions of Employment
Training

Other

Telework
Termination

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Month 2022 - Page 1

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.
a. The Role of the EEO Counselor

g. 45-Day Requirement to Contact EEO Counselor

b. The Individual or Class Complaint Process

h. Notify EEO Office of Attorney/Non-Attorney Representative

c. The Basis(es) to File a Complaint (Informal/Formal/Class)

i. Formal Stage Requirement of Attorney to Submit Billing Data

d. The Right to File a Complaint

j. Witness(es) Rights

e. Avenues of Redress

k. ADR Program

f. Rights and Responsibilities

l. Informal Complaint Process

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

Yes

Yes

No

No

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

Yes

Yes

No

No
14. DATE OF THIS COUNSELING SESSION

13. SIGNATURE OF EMPLOYEE/FORMER EMPLOYEE/APPLICANT

(Month, Day, Year)

DATE OF COUNSELING SESSION

NAME OF EEO COUNSELOR

SIGNATURE OF EEO COUNSELOR

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Month 2022 - Page 2

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 th<:
time to read the instructions, look through existing records, gather and maintain the required data, and review the fom
or response. Ifyou 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 OMB control number or if
we fail to provide you with this notice. This collection has been assigned an OMB 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

FCC 5621
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