ETA Form 9039, Par Complaint Form – Equal Employment Opportunity in Apprent

OMB No. 1205-0NEW

Expiration Date: XX/XX/XXXX

Complaint Form – Equal

Employment Opportunity in Apprenticeship Programs

U.S. Department of Labor

Employment and Training Administration

Office of Apprenticeship

Instructions: Before completing this form, please read all instructions, including the Privacy Act statement below. Use this form to file a complaint of discrimination. This form constitutes notification that a formal Equal Employment Opportunity Complaint is being filed with the U.S. Department of Labor (USDOL).

Privacy Act Notice: The Privacy Act of 1974 requires that the USDOL provide the following statements to each individual from whom it requests information.

The authority for collecting this information is the National Apprenticeship Act of 1937.

The submission of this information is voluntary.

The information is used to process complaints under the above Act.

A copy of this complaint will be provided to the sponsor against whom it is filed. The information collected may be verified with persons who have knowledge pertinent to the complaint, may be used in the course of settlement negotiations with the sponsor and/or in the course of presenting evidence at a hearing, or may be disclosed to other agencies with jurisdiction over the complaint. Only the text of your complaint will be disclosed to the Sponsor and/or Employer. To the extent permitted by law, your actual name and address will not be disclosed.

Failure to provide the information will restrict the action the USDOL can take on your behalf.

Non-Retaliation: Federal (Office of Apprenticeship, “OA”) regulations require sponsors and employers to take all necessary steps to assure that there is no retaliation against any person who files an employment discrimination complaint or alleges a violation of 29 CFR Part 30; opposes employment discrimination; provides information to, assists, or participates in any manner in employment discrimination proceedings; or otherwise takes action that he or she has a right to take under applicable laws and regulations. This includes any intimidation, threat, coercion or discrimination. Please notify the OA State Representative immediately if any alleged attempt at retaliation is made and file a Complaint Form.

All complaints must be filed within 300 days of the alleged discrimination or alleged failure to follow equal opportunity standards. Exceptions to this time frame must be fully justified and approved by the USDOL.

Name of Complainant:

Street Address:

City:

State: ZIP Code:

Telephone No:

Apprenticeship Program Sponsor:

Street Address:

City: State: ZIP Code:

Date of discrimination or failure to follow equal opportunity standards:

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Alleged Unlawful Conduct:

Check mark one, any, or all of the appropriate basis (bases) you believe was (were) at issue.

1. Race 2. Color 3. Religion 4. Sex (Including Pregnancy and Gender identity)

5. National Origin 6. Age 7. Genetic Information 8. Disability

9. Sexual Orientation 10. Retaliation

THE COMPLAINT

Describe in detail the alleged discriminatory act(s) or alleged failure to follow equal opportunity standards, indicating place, names and titles or person involved. (Additional pages may be added to this form.)

Signature and Date of Complainant or the Complainant’s Authorized Representative:

_____________________________________________Date:________________

Depending on your State, please mail your complaint to the State Registration Agency or to U.S. Department of Labor, Office of Apprenticeship. 200 Constitution Ave., NW Washington, DC 20210 Att'n: Apprenticeship EEO Complaints. You may also scan the complaint form and email it to [email protected].

The collection and maintenance of the data on ETA-9039, Complaint Form – Equal Employment Opportunity in Apprenticeship Programs, is authorized under the National Apprenticeship Act, 29 U.S.C. 50, and its implementing regulations at 29 CFR part 29, subpart A and part 30. The data is used for apprenticeship program statistical purposes and is maintained, pursuant to the Privacy Act of 1974 (5 U.S.C. 552a.). Data may be disclosed to a State Apprenticeship Agency to determine an assessment of skill needs and program information, and in connection with federal litigation or when required by law.

Public Burden Statement: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Public reporting burden for this collection of information, which is voluntary, 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 information. While use of this form is optional, a fully completed ETA Form 9039 provides the information required by 29 CFR part 30 to request an investigation of your complaint.  The regulations require that all Equal Employment Opportunity complaints under apprenticeship training programs be in writing. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employment and Training Administration, Office of Apprenticeship, Room C-5321, Washington, D.C. 20210 or email [email protected] and reference OMB Control Number 1205-0NEW.

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