DHS Form 3090-1: Individual Complaint of Employment Discrimination

In Box 1, enter your name as Last, First, Middle Initial.

In Box 2, telephone (Include Area Code) and email: enter the Home and Work telephone, the Email Address and the Alternate Email Address.

In Box 3, Home Address, enter your Street Address, City, State and Zip Code; you must notify the Department of any change of address while complaint is pending, or your complaint may be dismissed.

In Box 4, if you are a current or former employee of the Federal Government, list your recent Title, Series, and Grade.

In Box 5, Name and address of organization where you work (If a Department of Homeland Security Employee), enter the Bureau or Component, Office and Organizational Unit, Street Address, City, State and Zip Code.

In Box 6, Employment status in relation to this complaint, mark Applicant, Probationary, Career/Career Conditional, Uniformed Service Member, Former Employee/Member, Retired or Other (Specify); enter the Date Left Department or the Date of Retirement where it applies.

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.

In Part II, print the name of your representative after "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.

In Part II, mark YES or NO for Is the representative an attorney?

In Part II, Box 9 is the Representative's mailing address: Firm/Organization, Street Address, City, State, & Zip Code; Box 10 is the Representative's employer (If Federal Agency); Box 11 is the Representative's telephone (Include Area Code)/Email, with Telephone and Email Address; Box 12a is the Complainant's Signature and Box 12b is the Date.

In Box 7, I certify that all statements made in this complaint are true, complete, and correct to the best of my knowledge and belief.

You must sign and date your complaint: sign on SIGNATURE OF COMPLAINANT OR ATTORNEY REPRESENTATIVE and enter the DATE.

Your representative need not be an attorney, but only an attorney representative may sign the complaint on your behalf.

In Part III, Box 13 is the Name of person or DHS component who took the action at issue, with Organization, Street Address, and City, State, & Zip Code.

Box 14: are you willing to participate in mediation or other available types of alternative dispute resolution to resolve your complaint? Mark NO or YES.

In Box 15A, describe the action taken against you that you believe was discriminatory.

In Box 15B, give the date when the action occurred, and the name of each person responsible for the action.

In Box 15C, describe how you were treated differently from other employees, applicants, or members for any of the reasons listed in Item 16.

In Box 15D, 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.)

In Box 15E, if the basis of your complaint is based on parental status, use this form, but your complaint is not statutorily based and will follow separate, parallel process.

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 Part III should be brief, clear, and complete.

Item 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), GENDER (Specify), Pregnancy, Gender Identity, Sexual Orientation, PARENTAL STATUS, GENETIC INFORMATION, AGE (Year of Birth), PHYSICAL OR MENTAL DISABILITY (Describe) and RETALIATION/REPRISAL (Dates of Prior EEO Activity).

Box 17: What remedial or corrective action are you seeking to resolve this matter?

Box 18: on this same matter, have you filed a grievance or appeal under: Negotiated grievance procedure, Agency grievance procedure or Merit Systems Protection Board appeal procedure? Mark NO or YES for each.

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

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.

Box 19 is the Date you contacted an EEO Counselor; Box 20 is the Name and Telephone number of the EEO Counselor.

Box 21: Did you discuss all actions raised in Item 15 with an EEO Counselor? Mark YES or NO; if NO, explain on attached sheet. Box 22 is the Date you received your "Notice of Right to File".

Box 23: if you are requesting amendment of an existing, open, formal complaint (or providing additional evidence), indicate the complaint case number of that complaint.

Box 24 is the Date of most recent discriminatory event; Box 25 is the Date you first became aware of the alleged discrimination.

In accordance with 29 CFR 1614.106(c), your written complaint must be signed by you or your attorney.

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.

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.