Dhs Form 3090 1 PDF Details

The DHS 3090 1 form represents a critical component in the process of addressing and resolving employment discrimination within the Department of Homeland Security (DHS). It serves as the foundational step for individuals who believe they have been subjected to discriminatory practices because of race, color, religion, sex, national origin, age, physical or mental disabilities, genetic information, reprisal, parental status, or sexual orientation. Designed for both initial complaints and amendments, this document facilitates the formal voicing of grievances by current or former employees, as well as applicants for DHS positions. Crucially, it requests detailed information about the complainant, the alleged discriminatory actions, and the desired outcomes for resolution. In addition to providing a platform for individuals to certify the truth of their statements, the form outlines the necessity of nominating a representative, which does not have to be an attorney, although one can serve in this capacity if chosen. Moreover, it highlights the importance of early engagement with an Equal Employment Opportunity (EEO) counselor as part of the complaint's procedural flow. This form must be completed thoroughly as it can directly influence the investigation, potential mediation, and resolution phases that follow its submission. The guidance within clarifies critical deadlines, such as the 15 calendar days to file after receiving a "Notice of Right to File a Discrimination Complaint," underscoring the form's pivotal role in the timely and effective handling of discrimination complaints within DHS.

QuestionAnswer
Form NameDhs Form 3090 1
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesdhs form 560 1 pdf, form 3090, irs form 3090, dhs form 3090 1

Form Preview Example

OMB No. 1610-0001 Expiration Date: 8/31/14

DEPARTMENT OF HOMELAND SECURITY

INDIVIDUAL COMPLAINT OF EMPLOYMENT DISCRIMINATION

(Use this form for original complaints and amendments.)

FOR OFFICIAL USE ONLY

DEPARTMENT CASE NUMBER

FILING DATE

PART I COMPLAINANT IDENTIFICATION

1.NAME (Last, First, Middle Initial)

2.TELEPHONE/FAX (Include Area Code)

Home

Fax

 

 

Work

Fax

 

 

3. HOME ADDRESS (You must notify the Department of any

change of address while complaint is pending, or your

complaint may be dismissed.)

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

Bureau or Component

Office and Organizational Unit

Street Address

City

State

Zip Code

6. EMPLOYMENT STATUS IN RELATION TO THIS COMPLAINT

4. IF YOU ARE A CURRENT OR FORMER EMPLOYEE OF THE

FEDERAL GOVERNMENT, LIST YOUR RECENT TITLE,

SERIES, AND GRADE.

Title

SeriesGrade

Applicant Probationary

Uniformed Service Member

Former Employee/Member

Retired

Other (Specify)

Career/Career Conditional

Date Left Department

Date of Retirement

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.

"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."

Is the representative an attorney?

YES

NO

 

 

 

9. REPRESENTATIVE'S MAILING ADDRESS

10. REPRESENTATIVE'S EMPLOYER (If Federal Agency)

 

 

 

FIRM/ORGANIZATION

 

 

 

 

STREET ADDRESS

11. REPRESENTATIVE'S TELEPHONE/FAX (Include Area Code)

 

Telephone

Fax

CITY, STATE, & ZIP CODE

12a. COMPLAINANT'S SIGNATURE

12b. DATE

DHS Form 3090-1 (9/11)

Page 1 of 2

PART III ALLEGED DISCRIMINATORY ACTIONS

13.NAME OF PERSON OR DHS COMPONENT WHO TOOK THE ACTION AT ISSUE.

FIRM/ORGANIZATION

STREET ADDRESS

CITY, STATE, & ZIP CODE

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

YES

NO

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 parental status or sexual orientation, 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)

COLOR (Specify)

RELIGION (Specify)

NATIONAL ORIGIN (Specify)

SEX (Specify)

pregnancy

AGE (Date of Birth)

PHYSICAL OR MENTAL DISABILITY (Describe)

RETALIATION/REPRISAL (Dates of Prior EEO Activity)

GENETIC INFORMATION

SEXUAL ORIENTATION

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

YES

NO

 

Agency grievance procedure

YES

NO

 

Merit Systems Protection Board appeal procedure

YES

NO

 

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

 

 

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 22. DATE YOU RECEIVED YOUR "NOTICE OF RIGHT TO FILE" AN EEO COUNSELOR? (If NO, explain on attached sheet)

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 (9/11)

Page 2 of 2

OMB No. 1610-0001 Expiration Date: 8/31/14

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, 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 or sexual orientation. 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 within 45 days of the event giving rise to your claim, or within 45 days of 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.

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; 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, national origin, age, physical or mental disability, protected genetic information, 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:

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.

5.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.

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1. Before anything else, when filling in the dhs 3090 form, begin with the area that contains the following blank fields:

Part # 1 in completing dhs form 3090

2. When this part is completed, go to type in the applicable information in all these: Series, Grade, Retired, Other Specify, Date Left Department, Date of Retirement, I certify that all statements made, SIGNATURE OF COMPLAINANT OR, DATE, PART II DESIGNATION OF, YOU MAY REPRESENT YOURSELF IN THIS, I hereby designate Please Print, to serve, as my representative during the, and Is the representative an attorney.

Guidelines on how to fill in dhs form 3090 stage 2

It's easy to get it wrong when filling in your Retired, for that reason you'll want to look again before you decide to send it in.

3. The following step will be about Telephone, Fax, CITY STATE ZIP CODE, a COMPLAINANTS SIGNATURE, b DATE, DHS Form, and Page of - fill out each one of these blank fields.

Completing section 3 in dhs form 3090

4. Your next subsection needs your input in the following parts: NAME OF PERSON OR DHS COMPONENT, FIRMORGANIZATION, STREET ADDRESS, CITY STATE ZIP CODE, ARE YOU WILLING TO PARTICIPATE IN, YES, A Describe the action taken, B Give the date when the action, Mark below ONLY the bases you, RACE Specify, COLOR Specify, RELIGION Specify, AGE Date of Birth, and PHYSICAL OR MENTAL DISABILITY. Ensure you provide all of the needed information to move forward.

Filling in part 4 of dhs form 3090

5. As a final point, this final section is what you have to finish before using the PDF. The blank fields in this instance include the following: RELIGION Specify, NATIONAL ORIGIN Specify, SEX Specify, pregnancy, RETALIATIONREPRISAL Dates of Prior, GENETIC INFORMATION, SEXUAL ORIENTATION, PARENTAL STATUS, WHAT REMEDIAL OR CORRECTIVE, ON THIS SAME MATTER HAVE YOU, Negotiated grievance procedure, Agency grievance procedure, Merit Systems Protection Board, If you filed a grievance or appeal, and YES.

dhs form 3090 conclusion process outlined (stage 5)

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