Form DHS Form 3090-3 DHS Form 3090-3 DHS Individual Compliant of Employment Discrimination

OMB No. 1610-0001 Expiration Date: 6/30/2023

FOR OFFICIAL USE ONLY

DEPARTMENT OF HOMELAND SECURITY

INDIVIDUAL COMPLAINT OF EMPLOYMENT DISCRIMINATION
(Use this form for original complaints and amendments.)

DEPARTMENT CASE NUMBER
FILING DATE

PART I COMPLAINANT IDENTIFICATION
1. NAME (Last, First, Middle Initial)

5. NAME AND ADDRESS OF ORGANIZATION WHERE YOU
WORK (If a Department of Homeland Security Employee)

2. TELEPHONE (Include Area Code) AND EMAIL
Work
Home

Bureau or Component
Office and Organizational Unit

Email Address
Alternate Email Address

Street Address

3. HOME ADDRESS (You must notify the Department of any
change of address while complaint is pending, or your
complaint may be dismissed.)

City

State

Zip Code

6. EMPLOYMENT STATUS IN RELATION TO THIS COMPLAINT
Applicant

Probationary

Career/Career Conditional

Uniformed Service Member
4. IF YOU ARE A CURRENT OR FORMER EMPLOYEE OF
THE FEDERAL GOVERNMENT, LIST YOUR RECENT
TITLE, SERIES, AND GRADE.
Title

Former Employee/Member
Date Left Department
Retired
Date of Retirement
Other (Specify)

Series

Grade

7. I certify that all statements made in this complaint are true, complete, and correct to the best of my knowledge and belief.
SIGNATURE OF COMPLAINANT OR ATTORNEY REPRESENTATIVE

DATE

PART II DESIGNATION OF REPRESENTATIVE
8. YOU MAY REPRESENT YOURSELF IN THIS COMPLAINT OR YOU MAY CHOOSE SOMEONE TO REPRESENT YOU. YOUR
REPRESENTATIVE DOES NOT HAVE TO BE AN ATTORNEY. YOU MAY CHANGE YOUR DESIGNATION OF A
REPRESENTATIVE AT A LATER DATE, BUT YOU MUST NOTIFY THE DEPARTMENT IMMEDIATELY IN WRITING OF ANY
CHANGE, AND YOU MUST INCLUDE THE SAME INFORMATION REQUESTED IN THIS PART.
to serve as my

"I hereby designate (Please Print Name)

representative during the course of this complaint. I understand that my representative is authorized to act on my behalf."
Is the representative an attorney?

YES

NO

9. REPRESENTATIVE'S MAILING ADDRESS
FIRM/ORGANIZATION

10. REPRESENTATIVE'S EMPLOYER (If Federal Agency)

STREET ADDRESS

11. REPRESENTATIVE'S TELEPHONE (Include Area Code)/EMAIL
Telephone
Email Address

CITY, STATE, & ZIP CODE

12a. COMPLAINANT'S SIGNATURE

DHS Form 3090-1 (5/21)

12b. DATE

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PART III ALLEGED DISCRIMINATORY ACTIONS
13. NAME OF PERSON OR DHS COMPONENT WHO TOOK THE
ACTION AT ISSUE.
ORGANIZATION

14. ARE YOU WILLING TO PARTICIPATE IN MEDIATION OR
OTHER AVAILABLE TYPES OF ALTERNATIVE DISPUTE
RESOLUTION TO RESOLVE YOUR COMPLAINT?

YES

NO

STREET ADDRESS
CITY, STATE, & ZIP CODE
15. A. Describe the action taken against you that you believe was discriminatory.
B. Give the date when the action occurred, and the name of each person responsible for the action.
C. Describe how you were treated differently from other employees, applicants, or members for any of the reasons listed in
Item 16.
D. Indicate what harm, if any, came to you in your work situation as a result of this action. (You may, but are not required to,
attach extra sheets.)
E. If the basis of your complaint is based on parental status, use this form, but your complaint is not statutorily based
and will follow separate, parallel process.

16. Mark below ONLY the bases you believe were relied on to take the actions described in Item 15.
RACE (Specify)

AGE (Year of Birth)

COLOR (Specify)

PHYSICAL OR MENTAL DISABILITY (Describe)

RELIGION (Specify)

RETALIATION/REPRISAL (Dates of Prior EEO Activity)

NATIONAL ORIGIN (Specify)
GENDER (Specify)
Pregnancy

Gender Identity

Sexual Orientation

GENETIC INFORMATION
PARENTAL STATUS

17. WHAT REMEDIAL OR CORRECTIVE ACTION ARE YOU SEEKING TO RESOLVE THIS MATTER

18. ON THIS SAME MATTER, HAVE YOU FILED A GRIEVANCE OR APPEAL UNDER:
Negotiated grievance procedure
Agency grievance procedure
Merit Systems Protection Board appeal procedure
If you filed a grievance or appeal, provide date filed, case number, and present status.

YES
YES
YES

NO
NO
NO

PART IV CONTACT
EEO/EO Counseling is not required if you are requesting amendment of an existing, open complaint.
Complete items 24 and 25, even if you did not contact a counselor.
19. DATE YOU CONTACTED AN EEO COUNSELOR

20. NAME AND TELEPHONE NUMBER OF EEO COUNSELOR
Name
Phone

21. DID YOU DISCUSS ALL ACTIONS RAISED IN ITEM 15 WITH
AN EEO COUNSELOR? (If NO, explain on attached sheet)

22. DATE YOU RECEIVED YOUR "NOTICE OF RIGHT TO FILE"

YES

NO

23. IF YOU ARE REQUESTING AMENDMENT OF AN EXISTING, OPEN, FORMAL COMPLAINT (OR PROVIDING ADDITIONAL
EVIDENCE), INDICATE THE COMPLAINT CASE NUMBER OF THAT COMPLAINT.
24. DATE OF MOST RECENT DISCRIMINATORY EVENT
25. DATE YOU FIRST BECAME AWARE OF THE ALLEGED
DISCRIMINATION
DHS Form 3090-1 (5/21)

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OMB No. 1610-0001 Expiration Date: 6/30/2023

DEPARTMENT OF HOMELAND SECURITY
DHS FORM 3090-1, INDIVIDUAL COMPLAINT OF EMPLOYMENT
DISCRIMINATION FORM INSTRUCTIONS
(Read the following instructions carefully before you complete this form.)
(Please complete all items on the complaint form.)
GENERAL: This form should be used only if you, as an applicant for employment with the Department of Homeland
Security (DHS), or as a present or former Department of Homeland Security employee:
1. believe you have been discriminated against because of your race, color, religion, sex (including pregnancy,
gender identity, and sexual orientation), national origin, age (40 years or older at the time of the event giving rise
to your claim), physical or mental disability, genetic information or in reprisal for opposition to activities
protected by civil rights statutes, or participation in proceedings to enforce those statutes; or
2. believe you have been discriminated against because of your parental status. Your claim is not covered under
statutory basis, but will be processed under a parallel procedure, and
3. have presented the matter for informal resolution to an Equal Employment Opportunity (EEO) Counselor giving rise
to your claim, or when first becoming aware of the alleged discrimination. If you are amending or providing
additional evidence to an existing open complaint, the form should be used, but EEO counseling is not required.
IMPORTANT NOTE: In certain situations, the information provided in Part III of the attached complaint form may be used in
lieu of an affidavit in the investigation of your complaint. Accordingly, the information you provide in this part should be brief,
clear, and complete.
WHEN TO FILE: In accordance with 29 CFR 1614.106, your formal complaint must be filed within 15 calendar days of the
date you received the "Notice of Right to File a Discrimination Complaint" from your EEO Counselor. You must sign and date
your complaint. If you are represented by an attorney, the attorney may sign the complaint on your behalf.
These time limits may be extended:
1)

if you show that you were not notified of the time limits and were not otherwise aware of them, or

2)

if you were prevented by circumstances beyond your control from submitting the matter within the time limits, or

3)

for other reasons considered sufficient by the Department.

REPRESENTATION: You may have a representative of your own choosing at all stages of the processing of your
complaint. However, your representative will be disqualified if such representation would conflict with the official or collateral
duties of the representative. No EEO Counselor, EEO Investigator or EEO Officer may serve as a representative. (Your
representative need not be an attorney, but only an attorney representative may sign the complaint on your behalf.)
WHERE TO FILE: In accordance with 29 CFR 1614.106(c), your written complaint must be signed by you or your attorney.
The complaint should be filed with the EEO Director of the Department of Homeland Security component where the alleged
discrimination occurred. (Filing instructions are contained in the "Right to File" form, which was provided by your Counselor.)
Keep a copy of the completed complaint form for your records.

DHS Form 3090-1 (5/21)

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PRIVACY ACT STATEMENT
1.

FORM/TITLE/DATE: Department of Homeland Security (DHS) DHS Form 3090-1, Individual Complaint of
Employment Discrimination with the Department of Homeland Security.

2.

AUTHORITY: 42 USC 2000e; 29 USC 633a; 29 USC 791; 5 USC 1303 and 1304; 5 CFR 5.2 and 5.3; 29 CFR
1614.105 and 1614.107; and Executive Order 11478, as amended.

3.

PRINCIPAL PURPOSES: The purpose of this complaint form, whether recorded initially on the form or taken from a
letter from the Complainant, is to record the filing of a formal written complaint of employment discrimination with the
Department of Homeland Security on the grounds of race, color, religion, sex (including pregnancy, gender identity,
and sexual orientation), national origin, age, physical or mental disability, protected genetic information, parental status
or retaliation. Information provided on this form will be used by DHS to determine whether the complaint was timely
filed and whether the allegations in the complaint are within the purview of 29 CFR Part 1614, to provide a factual basis
for investigation of the complaint, and to reach a decision on the complaint. It also records an amendment or additional
evidence to an open, pending complaint.

4.

ROUTINE USES: Other disclosures may be:

5.

a.

to respond to a request form from a Member of Congress regarding the status of the complaint or appeal;

b.

to respond to a court subpoena and/or to refer to a district court in connection with a civil suit;

c.

to disclose information to authorized officials or personnel to adjudicate a complaint or appeal; or

d.

to disclose information to another Federal agency or to a court or third party in litigation when the
Government is party to a suit before the court.

WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY, AND EFFECT OF NOT PROVIDING INFORMATION:
Formal complaints of employment discrimination must be in writing, signed by the Complainant (or attorney
representative), and must identify the parties and action or policy at issue. Failure to comply may result in the
Department of Homeland Security dismissing the complaint. It is not mandatory that this form be used to provide the
requested information.

OMB STATEMENT
In accordance with the Paperwork Reduction Act, no persons are required to respond to a collection of information unless it
displays a valid OMB Control Number. The valid OMB Control Number for this information collection is 1610-0001. The time
required to complete this information collection is estimated to average 30 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information.

DHS Form 3090-1 (5/21)

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