Ngb Form 713 5 PDF Details

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QuestionAnswer
Form NameNgb Form 713 5
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesngb form 23, acepted, MSPB, EEO

Form Preview Example

PAGE 1 OF 3 PAGES

FORM AL DISCRIM INATION COM PLAINT IN T HE NAT IONAL GUARD

For use of this form see NGR (AR) 6 90 -60 0/NGR (AF) 4 0 -1 6 14, the proponent is NGB-EO

NGB Case Number T-

PRIV ACY ACT STATEMENT

1 . Authority: Public Law 9 2 -2 6 1 amending 4 2 U. S.C. Section 2 0 00e

2 . Principal Purpose: Used by National Guard Technicians in filing a formal complaint of discrimination.

3 . Routine Uses: Used by National Guard Technicians in filing a formal complaint of discrimination. Used by State Adjutant General in accepting or dismissing complaints and w hen requesting investigations from the National Guard Bureau. The form becomes a part of the of ficial complaint file.

4 . Mandatory or Voluntary Disclosure and Ef fect on Individ ual not providing information. This form must be completed by a complainant in filing a formal complaint of discrimination. It is not mandatory in that complaints of discrimination w ill be acepted if submit ted 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 w ho 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 mat ter 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 mat ter as an informal complaint to an EEO Counselor or the SEEM w ithin 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 w ith an EEO Counselor. The Counselor

w ill assist you in statin g acceptable issues in clear terms. Any issues that are not clear and specific w ill be returned for clarification or may be dismissed.

TO BE COM PLETED BY SEEM

THE MATTERS GIVING RISE TO THE COM PLAINT W ILL BE CODED USING ONE OR M ORE OF THE FOLLOWING CODES:

 

CATEGORY

 

CODE

 

 

CATEGORY

 

 

CODE

 

CATEGORY

CODE

 

Appointment/Hire

 

(1)

Duty Ho urs

 

 

 

 

 

 

(1 0)

Reassignment

 

 

Assingment of Duties

 

(2)

Equal Pay Act Violation

 

 

 

 

 

 

(1 1)

Request Denied

(1 8)

 

Aw ards

 

(3)

Examinatio n/Test

 

 

 

 

 

 

(1 2)

Directed

(1 9)

 

Conversion to Full-Time

 

(4)

Evaluation/Appraisal

 

 

 

 

 

 

(1 3)

Reinstatement

(2 0)

 

Disciplinary Action:

 

 

Harassment

 

 

 

 

 

 

 

Retirement

(2 1)

 

Demotion

 

(5)

Non-Sexual

 

 

 

 

 

 

(1 4)

Time and At tendance

(2 2)

 

Reprimand

 

(6)

Sexual

 

 

 

 

 

 

(1 5)

Training/Education

(2 3)

 

Suspension

 

(7)

Pay Including Overtime

 

 

 

 

 

 

(1 6)

Terms/Conditios of Employment

(2 4)

 

Termination

 

(8)

Promotion/Non-Selection

 

 

(1 7)

Other

(2 5)

 

Other

 

(9)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ENTER CODE(S) FOR MATTER(S)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GIVING RISE TO THE COMMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE COUNSELOR CONTACTED

 

DATE OF INITIAL INTERVIEW

 

 

 

DATE 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, Mid dle)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

HOME ADDRESS (In clud ing Zip Co de)

 

 

 

 

 

 

 

3 . TELEPHONE NUMBERS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. BUSINESS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COM M

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DSN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. HOME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

ACTIVITY OR UNIT IN WHICH DISCRIMINATION TOOK PLACE:

 

5 . ARE YOU PRESENTLY A: (CHECK ONE)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Technician

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Applicant for Employment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Former Technician

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

LOCATION OF THE POSITION (If dif ferent from 4 . above)

 

 

 

 

 

 

 

 

 

 

 

 

NGB FORM 7 1 3 -5, JU NE 2 0 0 1 (EF)(A DOBE V. 4 .0)

PREVIOUS EDITIONS ARE OBSOLETE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PAGE 2 OF 3 PAGES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

 

CHECK BELOW THE BASES (Reasons) FOR ALLEGED DISCRIMINATION:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

R

RACE (Check Your Race)

 

 

 

Black

 

 

WHIT

 

American Indian/Alaskan Native

 

 

Asian/Pacific Islander

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A

AGE (State Your Age)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

G

GENDER(Not Sexual Harassment) (Check Your

 

 

Male

 

 

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gender)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

S

GENDER(Sexual Harassment) (Check Your Gender)

 

Male

 

 

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N

NATIONAL ORIGIN (State Your Natio nal Origin)

 

 

Hispanic

 

 

Other (Specif y)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

At torney at Law

 

 

Yes

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10 .

I

 

 

 

have

 

have n ot filed a greivance on this mat ter.

 

1 1. I

 

 

 

have

 

 

 

have not appealed to MSPB.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

13 . SPECIFIC ALLEGATION AND ISSUES (Explain how you b elieve y ou w ere discrimi nated 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 in dicate the name of the individual you believe discriminated against you.

SAMPLE: I w as discriminated against on (date) on the basis of (Race, Religion, or other bases) w hen (briefly list the discriminatory event(s) or personnel action).

.

NGB FORM 7 1 3-5 , JUNE 2 0 01

PAGE 3 OF 3 PAGES

13 . SPECIFIC ALLEGATION AND ISSUES (Cont inu ed)

14 . SIGNATURE OF COMPLAINANT

15 . DATE

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

NGB FORM 7 1 3-5 , JUNE 2 0 01

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