Form Ngb 713 5 R PDF Details

The Ngb 713 5 R form stands as a pivotal document within the National Guard Bureau's efforts to uphold equality and prevent discrimination among its ranks. Rooted in the authority of Title VII of the Civil Rights Act of 1964 and further reinforced by Title 29 Code of Federal Regulations, Part 1614, this form enables National Guard Technicians to formally report instances of discrimination they encounter within their employment. Designed to ensure that complaints are handled systematically and fairly, the form specifies a range of discrimination categories, including race, color, religion, gender, national origin, age, and physical or mental handicap. This formal complaint process necessitates initial efforts to resolve issues through informal channels, mandating engagement with an EEO Counselor or the SEEM within a 45-day timeframe from the incident's occurrence. The detailed structure of the Ngb 713 5 R form, from categorizing the nature of the complaint to outlining the complainant's desired corrective actions, ensures clarity and precision in addressing grievances. Importantly, the form also emphasizes the voluntary nature of disclosure, though insufficient information may hinder the complaint's progress. By serving as both a record of grievances and a tool for potential remedial action, the Ngb 713 5 R form embodies the National Guard Bureau's commitment to maintaining a workplace free from discrimination.

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Form NameForm Ngb 713 5 R
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesngb713_5_R ngb 713 5 r form

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Page 1 of 3

NATIONAL GUARD BUREAU

FORMAL COMPLAINT OF DISCRIMINATION

The proponent agency is NGB-EO. For use of this form, see NRG (AR) 690-600/NGR (AF) 40-1613.

PRIVACY ACT STATEMENT

1.AUTHORITY: Title VII of the Civil Rights Act of 1964, as amended 42 USC 2000e and Title 29 Code of Federal Regulations, Part 1614.

2.PRINCIPAL USES: Used by National Guard Technicians in filing a formal complaint of discrimination.

3.ROUTINE USES: Used by State Adjutant General in accepting or dismissing complaints and when requesting investigations from the National Guard Bureau. The form becomes a part of the official complaint file. This information may be disclosed to the state National Guard, National Guard, National Guard Bureau, Equal Employment Opportunity Commission, state or federal courts for reviews, decisions, and appeals of decisions. The National Guard Bureau is the official custodian of record.

4.DISCLOSURE: Disclosure is voluntary. A complainant in filing a formal complaint of discrimination must complete this form. It is not mandatory in that complaints of discrimination will be accepted if submitted in other formats. Failure to provide information as specified may result in delay or dismissal of a complaint.

INSTRUCTIONS

Any technician or applicant for technician employment who believes that he or she has been discriminated against because of race, color, religion, gender (including sexual harassment), national origin, age, or physical or mental handicap, in an employment matter subject to the control of the State National Guard or the National Guard Bureau, may file an individual complaint of discrimination. Before a formal complaint can be filed, the complainant must first present the matter as an informal complaint to an EEO Counselor or the SEEM within 45 calendar days from the date of the alleged discriminatory event or the personnel action took place. Each issue must state a specific incident, to include dates, so that its scope is clear. Also each issue must have been discussed with an EEO Counselor. The counselor will assist you in stating acceptable issues in clear terms. Any issues that are not clear and specific will be returned for clarification or may be dismissed.

TO BE COMPLETED BY SEEM

The matters giving rise to the complaint will be coded using one or more of the following codes:

CATEGORY

CODE

 

CATEGORY

CODE

 

CATEGORY

CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

Appointment/Hire

(1)

Duty Hours

 

 

(10)

Reassignment

 

Assignment of Duties

(2)

Equal Pay Act Violation

 

 

(11)

Request Denied

(18)

Awards

(3)

Examination Test

 

 

(12)

Directed

(19)

Conversion to Full-Time

(4)

Evaluation/Appraisal

 

 

(13)

Reinstatement

(20)

Disciplinary Action:

 

Harassment

 

 

 

Retirement

(21)

Demotion

(5)

Non-Sexual

 

 

(14)

Time and Attendance

(22)

Reprimand

(6)

Sexual

 

 

(15)

Training/Education

(23)

Suspension

(7)

Pay Including Overtime

 

 

(16)

Terms/Condition of Employment

(24)

Termination

(8)

Promotion/Non-Selection

 

 

(17)

Other

(25)

Other

(9)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ENTER CODE(S) MATTER(S)

 

 

 

 

 

 

 

 

 

 

 

 

GIVING RISE TO THE COMMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE COUNSELOR CONTACTED:

 

DATE OF INITIAL INTERVIEW:

 

DATE OF FINAL INTERVIEW:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE FILED WITH SEEM:

 

BASED ON:

POSTMARK

 

DELIVERY

 

 

 

 

 

 

 

 

 

 

 

 

 

FAXED

 

NO LEGIBLE POSTMARK (use 5 days before receipt)

 

 

 

 

 

 

 

 

 

 

 

 

 

1.NAME OF COMPLAINANT: (Last Name, First Name, Middle)

2. HOME ADDRESS: (Including Zip Code)

3. TELEPHONE NUMBERS

 

 

 

 

a. BUSINESS:

COMM:

 

 

 

 

 

DSN:

 

 

 

 

b. HOME:

 

 

 

 

3. ACTIVITY OR UNIT IN WHICH DISCRIMINATION TOOK PLACE:

5. ARE YOU PRESENTLY A: (Check one)

 

 

Technician

 

 

Applicant for Employment

 

 

Former Technician

 

 

 

NGB 713-5-R, 200106 (EF)(ADOBE V 8.0)

(PREVIOUS EDITIONS ARE OBSOLETE.)

 

 

 

 

 

 

 

 

 

 

 

 

Page 2 of 3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. LOCATION OF POSITION: (If different from 4)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7. CHECK BELOW THE BASES (Reasons) FOR ALLEGED DISCRIMINATION:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

R

RACE (Check Your Race)

African American

White

American Indian/Alaskan Native

Asian Pacific Islander

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A

AGE (State Your Age)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

G

GENDER

(Not Sexual Harassment)

 

Male

Female

 

 

 

 

 

 

(Check Your Gender)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

S

 

(Sexual Harassment)

 

 

 

 

 

 

 

 

 

 

 

 

GENDER (Check Your Gender)

 

Male

Female

 

 

 

 

 

 

N

NATIONAL ORIGIN (State Your National Origin)

Hispanic

Other

(Specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C

COLOR (State Your Color)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

H

HANDICAP (State Your Handicap)

 

Mental

Physical

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

L

RELIGION

(State Your Religion)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

O

RETALIATION (Based Upon EO/EEO Activity)

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. ARE YOU BEING REPRESENTED:

 

 

9. IF YES, NAME OF REPRESENTATIVE:

 

 

 

 

 

 

 

Yes (Complete 9)

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attorney at Law

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10. I

have

have not filed a grievance on this matter.

 

11. I

have

have not appealed a grievance on this matter.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12. WHAT CORRECTIVE ACTION DO YOU WANT TAKEN TO RESOLVE YOUR COMPLAINT?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13. SPECIFIC ALLEGATION AND ISSUES: (Explain how you believe you were discriminated against)

Issues

A. Number each issue.

 

B. List briefly the alleged act of discrimination, the basis, and the date(s) it took place.

 

C. Optional: You may indicate the name of the individual you believe discriminated against you.

SAMPLE: 1. I was discriminated against on (date) on the basis of (Race, Religion, or other Basis) when (briefly list the discrimination event(s) or personnel action).

NGB 713-5-R, 200106 (REVERSE)(ADOBE V 8.0)

Page 3 of 3

13. SPECIFIC ALLEGATION AND ISSUES: (Continued)

14. SIGNATURE OF COMPLAINANT:

DATE:

Do not date before you receive a Notice of Final interview and Right to File a Complaint from your EEO Counselor.

NGB 713-5-R, 200106 (CONTINUED)(ADOBE V 8.0)

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This document will require you to provide specific information; to ensure correctness, you need to take into account the subsequent guidelines:

1. Complete the Form Ngb 713 5 R with a number of essential blank fields. Note all the required information and be sure not a single thing overlooked!

Stage no. 1 of completing Form Ngb 713 5 R

2. When this section is complete, you need to insert the required details in LOCATION OF POSITION If different, CHECK BELOW THE BASES, Reasons, FOR ALLEGED DISCRIMINATION, RACE, Check Your Race, African American, White, American IndianAlaskan Native, Asian Pacific Islander, AGE, State Your Age, GENDER, Not Sexual Harassment Check Your, and GENDER so you're able to progress to the next stage.

Form Ngb 713 5 R completion process clarified (portion 2)

Concerning LOCATION OF POSITION If different and White, ensure you review things in this section. Both of these are viewed as the most important fields in the form.

3. The following segment is related to SAMPLE I was discriminated, and NGB R REVERSEAdobe v - type in all these blanks.

Best ways to fill out Form Ngb 713 5 R step 3

4. It's time to fill in this fourth part! In this case you have all of these SPECIFIC ALLEGATION AND ISSUES blanks to do.

Writing segment 4 of Form Ngb 713 5 R

5. Since you near the last sections of your file, you'll notice just a few extra requirements that have to be met. In particular, SIGNATURE OF COMPLAINANT, DATE, NGB R CONTINUEDAdobe v, and Do not date before you receive a must all be filled out.

How you can complete Form Ngb 713 5 R portion 5

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