OMB No: 2105-0556

                             PAPERWORK REDUCTION ACT BURDEN STATEMENT

Under the Paperwork Act of 1995, no persons are required to respond to a collection of information unless it displays valid OMB control number.  The public reporting burden for this voluntary collection of information is estimated to average 1 hour per response.  If you wish to comment on the accuracy of the estimate or make suggestions for reducing this burden, please direct your comments tothe 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 (gender, sexual harassment, pregnancy, sexual orientation, or gender identity), 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, or believe that you have been retaliated against for participating in activities covered under the Equal Employment Opportunity statutes; and

2)	have presented the matter for informal resolution to an EEO Counselor within 45-calendar days of the event giving rise to your claim, or within 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 within15-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 beextended:  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, Compliance Operations 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)

PRIVACY ACT STATEMENT

1.	FORM NUMBER/TITLEDATE:  Department of Transportation Form Number 1050-8, Individual Complaint of Employment Discrimination with the Department of Transportation.

2.	AUTHORITY:  42 U.S.C. 2000e; 29 U.S.C. 633a; PL 95-062 as amended; 5 U.S.C. 1303 and 1304; 5 C.F.R. 5.2 and 5.3; 29 C.F.R. 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 Transportation on the grounds of race, color, religion, sex (gender, sexual harassment, pregnancy, sexual orientation, or gender identity), national origin, age, physical or mental disability, genetic information, or reprisal, and to reach a decision on the complaint.  Information provided on this form will be used by the 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.

4.	ROUTINE USES:  Other disclosures may be:

a.	to respond to a request 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;
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.

5.	WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY, AND EFFECT ON INDIVIDUAL BY 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 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

           
DEPARTMENT OF TRANSPORTATION

INDIVIDUAL COMPLAINT OF EMPLOYMENT DISCRIMINATION WITH THE DEPARTMENT OF TRANSPORTATION 	FOR OFFICE USE ONLY
	
	DEPARTMENT CASE NUMBER
    	
	FILING DATE
   	
PART I    COMPLAINANT IDENTIFICATION INFORMATION	
1.   Name (Last, First, Middle Initial):
	5.    Name and Address of Organization Where You Work (If a Department of Transportation Employee):

Office and Staff Symbol:                                  

Street Address:                                                                 		

City:                                                 State:                  Zip Code:		
2.   Telephone/Fax (Include Area Code):

Home:                                      Fax:                                                                     __________________________________________                            
Work:                                       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):

Street Address

City                                               State                  Zip Code   		
	6.   Employment Status in Relation to this Complaint:

□  Applicant     □  Probationary     □  Career/Career Conditional

□  Former Employee______________________________
                                   Date Last Employed at Department
□  Retired                  _____________________________
                                   Date of Retirement
□  Other                    _____________________________
                                   Specify
	
4.   If you are a current or former employee of the Federal government, list your most recent title, series, and grade. 

Title                                                        Series        Grade    		
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                                                 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 Departmental Office of Civil Rights immediately in writing of any change, and you must include the same information requested in this Part.

“I hereby designate ___________________________________________________(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.   Representative’s Mailing Address:

Firm/Organization

Street Address

City                                               State                Zip Code	10.   Representative’s Employer (If Federal Agency):

	11.   Representative’s Telephone/Fax (Include Area Code):

_________________________________________________
Telephone:                                                        Fax:                                                                                              	

12.   SIGNATURE of Complainant (or ATTORNEY)           DATE	
PART III    ALLEGED DISCRIMINATORY ACTIONS	
13.   Name and Address of Agency/office that took the action at issue (if different than item 5.)

Office and Organizational Component
___________________________________________
Street Address

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

Position Title                                           Series                    Grade                     

Vacancy AnnouncementNo.                     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 (Gender, Sexual Harassment, Pregnancy, Sexual                    □  Genetic Information (Specify) _____________________  
     Orientation, or Gender Identity)___________________                                            
     _______________________________________________                □  Retaliation (Date(s) of prior EEO Activity) _________
                                                                                                                        ______________________________________________
 □  National Origin (Specify) _________________________                    ______________________________________________
                                                                                                                        ______________________________________________                                                                       
 □  Age (Date of Birth) ______________________________                     ______________________________________________
                                                                                                                                                                                                     	
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	

3. Awards

16. Reinstatement	

4. Conversion To Full-Time

17. Religious Accommodation	

5. Disciplinary Action
     A.  Demotion
     B.  Reprimand
     C.  Suspension
     D.  Termination
     E.  Other	
	
18. Retirement

	
6. Duty Hours	
	
19. Sex Stereotyping (LGBT-
       related discrimination only)

	
7. Evaluation/Appraisal	
	
20. Telework

	
8. Examination/Test	
	
21. Termination

	
9. Harassment
     A.  Non-Sexual
     B.  Sexual
     C.  Hostile Work Environment 
          (non-sexual)
     D.  Hostile Work Environment  
          (sexual)	
	
22. Terms/Conditions Of   
        Employment	

10. Medical Examination	
	
23. Time And Attendance

	
11. Pay Including Overtime	
	
24. Training

	
12. Performance Evaluation/     
        Appraisal	
	
25. Other	

13. Promotion/Non-Selection	

	
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 (gender, sexual harassment, pregnancy, sexual orientation, or gender identity), national origin, age (40 years or older), disability (mental and/or physical), genetic information, or in retaliation for your participation in the EEO complaint process or opposition to alleged discriminatory practices; (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?
_________________________________________________
Month                                       Day                                 Year	24.  When did you receive your Notice of Right to File a Discrimination Complaint?
___________________________________________
Month                                     Day                                        Year	
20.   When did you first become aware of the alleged discrimination?             _______________________________
                                  Month                   Day               Year	25.On this same matter, have you filed a grievance or appeal under: 

-	Negotiated Grievance procedures       □  YES      □  NO
-	Agency grievance procedure                □  YES      □  NO
-	MSPB appeal procedure                      □  YES      □  NO

If you filed a grievance or appeal, provide date filed, case number, and present status.

____________________________________________________	
21.   When did you contact an EEO Counselor?
_________________________________________________
Month                                     Day                                     Year		
22.   Did you discuss ALL actions raised in item 17 with an EEO Counselor?        □  YES                 □   NO
(If no, explain on attached sheet)		
23.   Name and Telephone number of EEO Counselor

______________________________    ______________
                       Name                               Telephone No.