Form 7510 – Fill Out and Use This PDF

ROUTINE USES: Information will be used (a) as a data source for complaint information for production of summary descriptive statistics and analytical studies of complaints processing and resolution efforts; (b )to respond to general requests for information under the Freedom of Information Act; (c ) to respond to requests from legitimate outside individuals or agencies

(White House, Congress, Equal Employment Opportunity Commission) regarding the status of a complaint or appeal; or

(d)to adjudicate complaint or appeal.

DISCLOSURE: Voluntary, however, failure to complete all appropriate portions of this form may lead to delay in processing and/or rejection of complaint on the basis of inadequate data on which to continue processing.

SECTION l - PRE-COMPLAINT INTAKE INTERVIEW

4. PAY PLAN/SERIES/	5. DUTY ORGANIZATION (Complete address including office symbol)
GRADE

6.	WORK TELEPHONE	7. HOME TELEPHONE	8. HOME ADDRESS
9.	DATE OF ALLEGED	10. 45THCALENDAR DAY		11.	REASON FOR DELAYED CONTACT BEYOND 45 DAYS, IF APPLICABLE
DISCRIMINATORY ACTION		AFTER EVENT (YYYYMMDD)
(YYYYMMDD)
12. DATE OF INITIAL		13. 30TH CALENDAR DAY		14.	90TH CALENDAR DAY AFTER	15. DATE COUNSELING
CONTACT WITH EEO		AFTER INITIAL CONTACT WITH		INITIAL CONTACT WITH EEO OFFICIAL		EXTENSION GRANTED, IF
OFFICIAL (YYYYMMDD)		EEO OFFICIAL (YYYYMMDD)		(YYYYMMDD)		APPLICABLE (YYYYMMDD)

SECTION II - ORGANIZATION WHERE ALLEGED DISCRIMINATION OCCURRED (Complete address including office symbol)

SECTION III - RESPONDING MANAGEMENT OFFICIAL(s) INFORMATION (Include name, complete work address and phone number if known.)

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SECTION IV - BASIS OF COMPLAINT (Identify specific race, color, religion, national origin, disability, age, sex, or reprisal if alleged.)

(Date(s) of prior EEO activity)

SECTION V - MATTER(S) GIVING RISE TO COMPLAINT (Specify who, what, where, and when.) (Use additional sheet of paper if necessary.)

SECTION Vl - RELIEF SOUGHT

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SECTION Vll - RIGHTS AND RESPONSIBILITIES

THE AGGRIEVED WAS PROVIDED WITH THE AGGRIEVED PERSON'S RIGHTS AND RESPONSIBILITIES NOTICE AND WAS SPECIFICALLY ADVISED OF THE FOLLOWING:

The basis(es) for filing pre-complaint, formal complaint, and/or class complaint, and of right to file a formal complaint of discrimination.

The pre-complaint, formal and/or class complaint process.

The 45-day calendar requirement from effective date of personnel action or of the date of the matter alleged to be discriminatory.

The role of the EEO counselor, including that the counselor is not an advocate for either the aggrieved person or the agency and acts strictly as a neutral.

The activity's Alternate Dispute Resolution ( ADR) Program and right to elect either ADR (if offered) or traditional EEO counseling.

The right to remain anonymous during the pre-complaint process.

The right to representation throughout the complaint process.

Responsibility of the aggrieved to notify the EEO office in writing of any change in address and/or phone number.

Responsibility of the aggrieved to notify the EEO office in writing of non-attorney or attorney representation, including address and phone number.

The possible election requirement between a negotiated grievance procedure, MSPB procedure and the EEO complaint process. The election options in age and wage-based discrimination complaints.

SECTION Vlll - ELECTION OF REPRESENTATION

ATTORNEY	NON-ATTORNEY	NON-REPRESENTATIVE
NAME OF REPRESENTATIVE		ADDRESS

SECTION IX - ALTERNATE DISPUTE RESOLUTION (ADR)

Matter determined not appropriate for ADR

(Aggrieved must sign and date)

Matter determined appropriate for ADR

(EEO Officer must initial and date)

Wishes to participate in ADR, if offered

(EEO Officer must initial and date)

Date of written offer of ADR

Date of Agreement to Participate in ADR

Name of assigned ADR facilitator/mediator

Date ADR facilitator/mediator assigned

Result of ADR:

ADR was successful. Negotiated settlement agreement, signed on(YYYYMMDD), is attached.

ADR was not successful. The aggrieved was issued a Notice of Right to File a Formal Complaint of Discrimination on

(YYYYMMDD) and notified of requirement to file a formal complaint within 15 calendar days after receipt of Notice of Right to File. The aggrieved was provided a DA Form 2590, Formal Complaint of Discrimination.

SECTION X - TRADITIONAL EEO COUNSELING (EEO official to complete only those which apply.)

Election of traditional counseling.

Name of assigned EEO counselor

Date EEO counselor assigned

Election to remain anonymous.

Election to waive right to remain anonymous.

Declined to pursue matter under Title VII.

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SECTION Xl - WITNESS INQUIRY

a.Witness Information (List all witness data here. Number sequentially and include name, title, organization, phone number, and relevant basis(es) information.)

b. Witness Statements

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SECTION Xl - WITNESS INQUIRY (Cont'd)

Witness Statements (Cont'd)

c. Documents Reviewed (List)

d. Reviewed Documents Revealed

SECTION Xll - OUTCOME OF PRE-COMPLAINT INQUIRY

Resolution was not accomplished, therefore, I conducted the final interview with aggrieved on						(YYYYMMDD) at which
time I informed the aggrieved of the full scope of my inquiry and the reason(s) articulated by management for action(s) taken.
I provided the aggrieved with a Notice of Right to File a Formal Complaint of Discrimination and a DA Form 2590, Formal Complaint of
Discrimination. The aggrieved is aware of the requirement to file a formal complaint within 15 calendar days of the final interview if not
satisfied with the results of my inquiry.
Resolution was accomplished. Negotiated settlement agreement, signed on				(YYYYMMDD), is attached.
PRINTED NAME OF EEO COUNSELOR	SIGNATURE OF EEO COUNSELOR
Attachments:					DATE SUBMITTED TO EEO OFFICER
1. Extension of counseling (if applicable)					(YYYYMMDD)
2. Copies of reviewed documents
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