Dhs Form 3090 1 – Fill Out and Use This PDF

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.