Ps Form 2564 A – Fill Out and Use

On _________________________________, you requested an appointment with a Dispute Resolution Specialist.

Month, Day, Year

Important: Please Read. You should complete this form and return it to the EEO office within 10 calendar days of receipt. This the only notification that you will receive regarding the necessity for you to complete this form.

A. Requester Information

Your Mailing Address

Address of Postal Facility					Email Address *
Employment Status (Check One)				Position Title		Grade Level
Applicant	Casual	TE	Career
Pay Location	Tour	Duty Hours		Off Days (If Tour I, Show Nights Off)		Time in Current Position
						____ Years		____ Months
Your Supervisor’s Name				Supervisor’s Title		Supervisor’s Telephone No.
						(	)

*Providing this information will authorize the U.S. Postal Service to send you important documents electronically.

B. Discrimination Factors

Prohibited discrimination includes actions taken based on your Race, Color, Religion, Sex, Age (40+), National Origin, Physical and/or Mental

Disability, or in Retaliation (actions based on your participation in prior EEO activity). These categories are referred to on this form as factors.

What Factor(s) of Discrimination Are You Alleging? (Please be specific, i.e., Race - African American, Sex - Female.)

For Retaliation Allegations Only: If you are alleging retaliation discrimination, provide the date(s) and specifics of the EEO activity which you feel caused you to be retaliated against.

1.	On ___________________________, I engaged in EEO activity.	Case No.: __________________________.
	Month, Day, Year
2.	On ___________________________, I engaged in EEO activity.	Case No.: __________________________.
	Month, Day, Year

C. Description of Incident/Activity

Please use the space below to briefly describe the incident or action that prompted you to seek EEO counseling at this time.

On _____________________________________, 20____,

	Month, Day	Year

PS Form 2564-A, March 2001 (Page 1 of 3)

D. Comparisons

Explain why, based on the factors you cited in Section B, you believe that you were treated differently than other employees or applicants in similar situations.

1.

(Name of Employee)

Factor(s) that describe the employee, i.e., sex (male), National Origin (Hispanic)

was treated differently than I when:

2.

(Name of Employee)

Factor(s) that describe the employee, i.e., sex (male), National Origin (Hispanic)

was treated differently than I when:

3.

(Name of Employee)

Factor(s) that describe the employee, i.e., sex (male), National Origin (Hispanic)

was treated differently than I when:

E. Official(s) Responsible for Action(s)

List the name(s) of the official(s) who took the action which prompted you to seek counseling at this time.

Retaliation Allegations Only: Was/were the official(s) listed in Section E above aware of your prior EEO activity?

Yes	No	If yes, explain how the official(s) became aware:

F. Resolution

What are you seeking as a resolution to your pre-complaint?

G. Grievance/MSPB Appeal

On the incident that prompted you to seek EEO counseling, have you:

1.	Filed a grievance on the issue?	No	Yes	If yes,
					(Date)		(Current Step)
2.	Filed an MSPB appeal on this issue?	No	Yes	If yes,
					(Date Appeal Filed)

PS Form 2564-A, March 2001 (Page 2 of 3)

H. Anonymity

You have the right to remain anonymous during the pre-complaint process.

I. Representation

You have the right to retain representation of your choice. (Check One)

I waive the right to representation at this time.

I authorize the person listed below to represent me.

Mailing Address (Street or P.O. Box, City, State and ZIP + 4)

*Providing this information will authorize the U.S. Postal Service to send your representative important documents electronically.

J. Documentation

Please attach any documentation you wish to submit to support your allegation(s) Include a copy of any written action(s) that caused you to seek counseling at this time.

Note: If you are alleging mental and/or physical disability, it is important for you to submit medical documentation of your disability during the pre- complaint process.

K. Privacy Act Statement

L. Authorization

I am aware that the claim(s) contained herein shall by-pass the pre-complaint process if like or related to a formal complaint that I have already filed, or if the claim(s) constitutes a spin-off complaint. (A spin-off complaint contests the manner in which a previously filed complaint is being processed.) In completing this PS Form 2564-A, Information for Pre-Complaint Counseling, I recognize that the Manager, Dispute Resolution, will review the claim(s) contained herein and determine how they shall be processed. I will be notified, in writing, if the Manager determines that my claim(s) shall be processed as amendments or appendages to a formal complaint that I have already filed.

Please Print Your Name Here

Please Return This Form to:

EEO Processing

P O Box 1017

Dallas, Texas 75221-1017

PS Form 2564-A, March 2001 (Page 3 of 3)