Complaint Discrimination Federal Form – Fill Out and Use This PDF

COMPLAINT OF DISCRIMINATION IN THE				FOR AGENCY USE
FEDERAL GOVERNMENT
(This form is subject to the Privacy Act of 1974)
(See Page 3 for Privacy Act Statement and Iinstructions - Please type or print)
1. FULL NAME OF COMPLAINANT (Last, First, Middle Initial)				2. TELEPHONE NUMBER (Include
				Area Code)
3. ADDRESS (Street, City, State, and ZIP Code)				a. HOME
				(	)
				b. OFFICE
				(	)
4. FEDERAL OFFICE YOU BELIEVE DISCRIMINATED AGAINST YOU	5. ARE YOU NOW WORKING			FOR THE FEDERAL GOVERNMENT?
(Prepare a separate complaint form for each office which you believe		(If answer is "Yes" complete a, b, and c below.)
discriminated against you.)
			YES		NO
a. NAME OF OFFICE THAT YOU BELIEVE DISCRIMINATED AGAINST YOU	a. NAME OF AGENCY WHERE YOU WORK

8.CHECK BELOW WHY YOU BELIEVE YOU WERE DISCRIMINATED AGAINST

a.RACE (If so, state your race)

b.COLOR (If so, state your color)

c.RELIGION (If so, state your religion)

d.NATIONAL ORIGIN (If so, state your national origin)

e.SEX (If so, state your sex)

f.AGE (If so, state your age) (See Note 1)

g.DISABILITY (If so, state whether mental or physical)

h.SEXUAL HARASSMENT (If so, state your sex and the sex of the person you believe harassed you)

i.REPRISAL FOR PREVIOUS EEO ACTIVITY (If so, when)

j.GENETIC INFORMATION

k.PREGNANCY

Note 1: Complaints of discrimination because of age apply only to employees or applicants who were at least 40 years of age at the time the discriminatory action is alleged to have occurred.

9.EXPLAIN IN SPECIFICS HOW YOU BELIEVE YOU WERE DISCRIMINATED AGAINST (treated differently from other employees or applicants)

DUE TO YOUR RACE, COLOR, RELIGION, NATIONAL ORIGIN, SEX, AGE, PREGNANCY, GENETIC INFORMATION, DISABILITY, OR REPRISAL (For each allegation, please state to the best of your knowledge, information and belief what incident occurred and when the incident occurred.

If you need more space, continue on another sheet of paper.)

DD FORM 2655, JUN 2012	PREVIOUS EDITION IS OBSOLETE.	Page 1 of 3 Pages
		Adobe Professional 8.0

10.

I HAVE DISCUSSED MY COMPLAINT WITH AN EQUAL EMPLOYMENT

11. NAME OF COUNSELOR (If applicable)

OPPORTUNITY COUNSELOR (See instructions)

YES

NO

12.

HAVE THE ISSUES IDENTIFIED IN BLOCK 9 BEEN APPEALED TO THE MERIT SYSTEMS PROTECTION BOARD (MSPB) OR FILED UNDER

A UNION NEGOTIATED GRIEVANCE PROCEDURE?

NO

YES (If Yes, complete 12.a., b., and c. below)

a. (X one)

b. DATE FILED (YYYYMMDD)

c. MSPB OR UNION DOCKET NUMBER (If known)

MSPB

UNION NEGOTIATED GRIEVANCE

13.

WHAT RELIEF ARE YOU SEEKING TO RESOLVE THIS COMPLAINT? (State specific corrective action desired for each allegation.)

14.

LIST NAME(S) OF WITNESS(ES) AND BRIEFLY STATE WHAT INFORMATION WITNESS MAY CONTRIBUTE TO THE INVESTIGATION OF

YOUR COMPLAINT.

15.

SIGNATURE OF COMPLAINANT

16. DATE OF THIS COMPLAINT

(YYYYMMDD)

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PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 136; 29 U.S.C. 791, 792, 793, and 795; DoD Directive 1440.1; and E.O. 12106.

PRINCIPAL PURPOSE(S): To establish case records and document the counseling, investigation, and adjudication of complaints of employment discrimination brought by applicants and current and former DoD employees against the DoD.

ROUTINE USE(S): Records may be provided to EEO officials, hearing examiners, investigators and arbitrators, or by representatives of the Equal Employment Opportunity Commission and the courts concerning the complaint and appeal. The Blanket Routine Uses found at http://dpclo.defense.gov/privacy/SORNs/blanket_routine_uses.html apply to these records. The specific routine uses found at http://dpclo.defense.gov/privacy/SORNs/govt/EEOCGOVT-1.html also apply to these records.

DISCLOSURE: Voluntary. However, if the individual does not furnish the information requested, processing the complaint may be delayed or impaired.

READ INSTRUCTIONS CAREFULLY

This form should be used only if you, as an applicant for Federal employment or a Federal employee, think you have been discriminated against due to race, color, religion, sex, national origin, age, pregnancy, genetic information, disability, or reprisal by a Federal agency and have presented the matter for informal resolution to an Equal Employment Opportunity Counselor within 45 calendar days of the date the incident occurred or, if a personnel action, within 45 calendar days of its effective date.

Your complaint must be filed within 15 calendar days of the date of your final interview with the Equal Employment Opportunity Counselor. If the matter has not been resolved to your satisfaction within 30 calendar days of your first interview with the Equal Employment Opportunity Counselor and the final counseling interview has not been completed within that time, you have the right to file a complaint at any time thereafter up to 15 days after the final interview.

These time limits may be extended if you show that you were not notified of the time limits and were not otherwise aware of them, or that you were prevented by circumstances beyond your control from submitting the matter within the time limits, or for other reasons considered sufficient by the agency.

If you need help in the preparation of your complaint, you may contact the Equal Employment Opportunity Counselor who provided you with your initial counseling, or you may secure help from a representative of your choice.

For complaints filed against the Immediate Office of the Secretary of Defense, the Joint Staff and all activities receiving administrative support from Washington Headquarters Services, the individuals designated to receive complaints are the Equal Employment Opportunity Officer or the Director, EEO, Office of the Secretary of Defense. Complaints generated within agencies outside the above designated activities must be filed with that agency's individual designated to receive complaints of discrimination, i.e., the Chief EEO Counselor.

You may have a representative of your own choosing at all stages of the processing of your complaints.

You will have an opportunity to talk with an investigator and present all the facts which you believe show discrimination. The investigator will not be under the jurisdiction of the head of that part of the agency in which the alleged discrimination took place.

After the investigation of your complaint has been completed, you will be furnished a copy of the Report of Investigation. You will be given an opportunity to request a hearing, which will be conducted by an Administrative Judge assigned by the Equal Employment Opportunity Commission (EEOC). The hearing will be held at a convenient time and place. At the hearing, you may present witnesses and other evidence on your behalf.

The final decision (in writing) will be made by the head of the agency or his or her designee. If a hearing is held on your complaint, the head of the agency or the designee will review the decision recommended by the Administrative Judge before making a final decision, and will furnish you with a transcript of the hearing, a copy of the findings, analysis, and recommended action of the Administrative Judge, along with the agency's final decision letter.

If you are not satisfied with the final agency decision, you have the right to appeal that decision within 30 calendar days after receipt to the Equal Employment Opportunity Commission, Office of Federal Operations, P.O. Box 77960, Washington, DC 20013.

If your complaint is based on race, color, religion, sex, national origin, pregnancy, genetic information, disability, or reprisal, you may file a civil action in an appropriate U.S. District Court within 90 days of receipt of the agency's decision or, if you elect to file an appeal with the Commission, you may still file a civil action in a Federal District Court within 90 days of the Commission's decision if you are dissatisfied with the decision.

If your complaint is based on race, color, religion, sex, national origin, pregnancy, genetic information, disability, or reprisal, you may file a civil action in an appropriate U.S. District Court if you have not received a final agency decision within 180 days of filing your complaint with the agency or if you have not received a final Commission decision within 180 days of filing your appeal with the Commission's Office of Federal Operations.

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