INDIVIDUAL COMPLAINT OF EMPLOYMENT DISCRIMINATION FORM 1050-8_FINAL0

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make suggestions for reducing this burden, please direct your comments to the U.S. Department of Transportation, Departmental Office of Civil Rights, S-34, 1200
New Jersey Avenue, SE., Washington, DC 20590.

U.S. Department of Transportation
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
Transportation, or as a present or former Department of Transportation employee:
1) believe you have been discriminated against because of your race, color, religion, sex, national origin,

age (40 years or older at the time of the event giving rise to your claim), physical or mental disability,
equal pay/compensation, genetic information, pregnancy, childbirth, or related medical conditions,
or believe that you have been retaliated against for participating in activities covered under the Equal
Employment Opportunity (EEO) statutes; and
2) have presented the matter for informal resolution to an EEO Counselor within forty-five (45) calendar

days of the event giving rise to your claim, or within forty-five (45) calendar days of first becoming aware
of the alleged discrimination.
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 C.F.R. § 1614.106, your formal complaint must be filed within fifteen
(15) calendar days of the date you received the Notice of Right to File a Discrimination Complaint form 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 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: The complaint should be filed with the Associate Director, Complaints and Investigations
Division (S-34), Departmental Office of Civil Rights, 1200 New Jersey Avenue, S.E., W76-401, Washington,
DC 20590. Filing instructions are contained in the Notice of Right to File a Discrimination Complaint form
which was provided by your EEO Counselor. Keep a copy of the completed complaint form for your records.
(PLEASE ALSO READ THE PRIVACY ACT STATEMENT ON THE REVERSE SIDE)

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Privacy Act Statement (5 U.S.C. § 552a, as amended):
AUTHORITY: 29 U.S.C. § 633a, Nondiscrimination on account of age in Federal Government employment; 29
U.S.C. § 791, the Rehabilitation Act of 1973; 5 U.S.C. §§ 1303-1304, Investigations, reports, loyalty
investigations, reports, and revolving fund; 42 U.S.C. § 2000e; Title VI of the Civil Rights Act of 1965; 5 C.F.R.
§ 5.2, Investigation, evaluations, and corrective actions; 5 C.F.R. § 5.3, Enforcement; 29 C.F.R. § 1614.105,
Equal Employment Opportunity (EEO) Pre-complaint processing; 29 C.F.R. § 1614.107, EEO Dismissals of
complaints; Executive Order 11478; and Executive Order 14173.
PURPOSE(S): DOT will use the information collected to process requests and document, investigate, and
respond to civil rights complaints, inquiries, and appeals. 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 Transportation on the grounds of race, color,
religion, sex , national origin, age, physical or mental disability, genetic information, pregnancy, childbirth, or
related medical conditions, or reprisal, and to reach a decision on the complaint. Information provided on this
form will be used by the U.S. Department of Transportation to determine whether the complaint was timely filed
and whether the claims in the complaint are within the purview of 29 C.F.R. Part 1614, and to provide a factual
basis for investigation of the complaint.
ROUTINE USE(S ,QDFFRUGDQFHZLWK'27¶VV\VWHPRIUHFRUGVQRWLFe, DOT/ALL 24 ± Departmental Office of
Civil Rights System ± 89 FR 79688 ± September 30, 2024, the information provided may be disclosed to the U.
6'HSDUWPHQWRI-XVWLFHLQFOXGLQJ8QLWHG6WDWHV$WWRUQH\¶V2IILFHVRURWKHU)HGHUDODJHQF\FRQGXFWLQJ
litigation or in proceedings before any court, or adjudicative or administrative body, when it is necessary to the
litigation and one of the following is a party to the litigation or has an interest in such litigation. Exemptions
DSSO\WRWKLVV\VWHP$FRPSUHKHQVLYHOLVWRIURXWLQHXVHVFDQEHIRXQGLQ'27$//DQG'27¶V*HQHUDO
Statement of Routine uses, 75 FR 82138 (Dec. 29, 2010), 77 FR 42796 (July 20, 2012), 84 FR 55222 (Oct. 15,
2019). Other disclosures may be:
1.
2.
3.
4.

to respond to a request from a Member of Congress regarding the status of the complaint or appeal;
to respond to a court subpoena or to refer to a district court in connection with a civil suit;
to disclose information to authorized officials or personnel to adjudicate a complaint or appeal; or
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.

DISCLOSURE: Provision of the requested information is voluntary; however, failure to furnish the requested
information may result in an inability of the Department to process any internal or external civil rights
complaints, appeals, or inquiries from a party. 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 U.S. Department of Transportation dismissing the
complaint. It is not mandatory that this form be used to provide the requested information.

DETACH AND KEEP THIS PAGE WHEN YOU FILE YOUR COMPLAINT

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FOR OFFICE USE ONLY

DEPARTMENT OF TRANSPORTATION
INDIVIDUAL COMPLAINT OF EMPLOYMENT
DISCRIMINATION WITH THE DEPARTMENT OF
TRANSPORTATION
DEPARTMENT CASE NUMBER
FILING DATE

PART I

COMPLAINANT IDENTIFICATION INFORMATION
4. If you are a current or former employee of the Federal
government, list your most recent title, series, and grade.

1. Name (Last, First, Middle Initial):

Title
Series
Grade
5. Name and Address of Organization Where You Work (If a
Department of Transportation Employee):

2. Telephone/Fax (Include Area Code):
Home:

Fax:
Office and Staff Symbol:

Work:

Street Address:

Fax:

E-Mail:
3. Present Home Address (You must notify the
Departmental Office of Civil Rights of any changes to your
address while the 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

Former Employee
Date Last Employed at Department
Street Address
Retired
Date of Retirement
Other
City
State
Zip Code
Specify
7. I certify that all of the statements made in this complaint are true, complete, and correct to the best of my knowledge and
belief.
Signature of Complainant or ATTORNEY Representative

PART II

Date

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
Departmental Office of Civil Rights immediately in writing of any change, and you must include the same information
requested in this Part.
³,KHUHE\GHVLJQDWH(Please Print Name)
to serve as my representative during the course of this
complaint. I understand that my representative is authorized to act on my behalf.
9. 5HSUHVHQWDWLYH¶V0DLOLQJ$GGUHVV
 5HSUHVHQWDWLYH¶V7HOHSKRQH)D[(Include Area Code):
Firm/Organization
Street Address
Telephone:
Fax:
City
State
Zip Code
 5HSUHVHQWDWLYH¶V(PSOR\HU(If Federal Agency):
12. SIGNATURE of Complainant (or ATTORNEY)
DATE

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DOT F 1050-8 (02/24)

PART III

ALLEGED DISCRIMINATORY ACTIONS

13. Name and Address of Agency/office that took the action
at issue (if different than item 5.)

14. If your complaint involves non-selection for a position,
please complete the following:

Office and Organizational Component

Position Title

Series

Grade

Street Address
Vacancy Announcement No.
City
State
Zip Code
Date Learned of Non-Selection
15. Mark below ONLY the basis(es) you believe were relied on to take the actions described in #17.
Race (Specify)

Mental Disability (Specify)

Color (State Complexion)

Physical Disability (Specify)

Religion (Specify)

Equal Pay/Compensation (Specify)

Sex (Specify)

Genetic Information (Specify)

Retaliation (Date(s) of prior EEO Activity)

National Origin (Specify)

Age (Date of Birth)

Pregnant Workers Fairness Act (Specify)

16. Mark below ONLY the claim(s) you believe were relied on to take the actions described in #17.
1. Appointment/Hire

14. Reassignment
A. Denied
B. Directed

2. Assignment Of Duties

15. Reasonable Accommodation
± Disability
± Pregnant Workers Pregnant Fairness Act (PWFA)

3. Awards

16. Reinstatement

4. Conversion To Full-Time

17. Religious Accommodation

5. Disciplinary Action

18. Retirement

A. Demotion
B. Reprimand
C. Suspension
D. Termination
E. Other

6. Duty Hours

19. Sex Stereotyping (LGBTrelated discrimination only)

7. Evaluation/Appraisal

20. Telework

8. Examination/Test

21. Termination

9. Harassment

22. Terms/Conditions Of
Employment

A. Non-Sexual
B. Sexual
C. Hostile Work Environment
(non-sexual)
D. Hostile Work Environment
(sexual)

10. Medical Examination

23. Time And Attendance

11. Pay Including Overtime

24. Training

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DOT F 1050-8 (02/24)

12. Performance Evaluation/
Appraisal
13. Promotion/Non-Selection

25. Other

17. (A) Describe the action taken against you that you believe was discriminatory; (B) Give the date the action occurred, and
the name of each person responsible for the action; (C) Describe how you were treated differently than other employees or
applicants because of your race, color, religion, sex, national origin, age (40 years or older at the time of the event giving rise to
your claim) physical or mental disability, equal pay/compensation, genetic information, pregnancy, childbirth, or related
medical conditions or in retaliation for participating in activities covered under the Equal Employment Opportunity (EEO)
statutes; (D) indicate what harm, if any, came to you in your work situation as a result of this action. (You may attach extra
sheets.)

18. What remedial or corrective action are you seeking?

PART IV

EEO COUNSELOR CONTACT

19. When did the most recent discriminatory event occur?

23. Name and Telephone number of EEO Counselor

Month
Day
Year
20. When did you first become aware of the alleged
discrimination?

Name
Telephone No.
24. When did you receive your Notice of Right to File a
Discrimination Complaint?

Month
Day
21. When did you contact an EEO Counselor?

Year

Month
Day
Year
25. On this same matter, have you filed a grievance or appeal
under:

Month

Year

Day

Negotiated Grievance procedures
Agency grievance procedure
MSPB appeal procedure

YES
YES
YES

NO
NO
NO

If you filed a grievance or appeal, provide date filed, case
number, and present status.
22. Did you discuss ALL actions raised in item 17 with an EEO Counselor?
(If no, explain)

YES

NO

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