Ps Form 2565 – Fill Out and Use This PDF

1. Name

2. SSN

3. Case No.

8.Position Title (USPS Employees Only)

9.Grade Level (USPS Employees Only)

10. Do You Have Veteran’s Preference Eligibility?

Yes

No

14. Type of Discrimination You Are Alleging

Race (Specify):

Color (Specify):

Religion (Specify):

National Origin (Specify):

Sex (Specify):

Age (40+) (Specify):

Retaliation (Specify Prior EEO Activity):

Disability (Specify):

15.Date on Which Alleged Act(s) of Discrimination Took Place

18.Did You Discuss Your Complaint with a Dispute Resolution Specialist or a REDRESS Mediator?

Yes (Date you received the Notice of Final Interview): __________________________________

No

19a. Signature of Dispute Resolution Specialist

19b. Date

20. Signature of Complainant or Complainant’s Attorney

21. Date of this Complaint

The collection of this information is authorized by the Equal Employment Opportunity Act of 1972, 42 U.S.C. § 2000e-16; the Age Discrimination in Employment Act of 1967, as amended, 29 U.S.C. § 633a; the Rehabilitation Act of 1973, as amended, 29 U.S.C. § 794a; and Executive Order 11478, as amended. This information will be used to adjudicate complaints of alleged discrimination and to evaluate the effectiveness of the EEO Program. As a routine use, this information may be disclosed to an appropriate government agency, domestic or foreign, for law enforcement purposes; where pertinent, in a legal proceeding to which the USPS is a party or has an interest; to a government agency in order to obtain information relevant to a USPS decision concerning employment, security clearances, contracts, licenses, grants, permits or other benefits; to a government agency upon its request when relevant to its decision concerning employment, security clearances, security or suitability investigations, contracts, licenses, grants

or other benefits; to a congressional office at your request; to an expert, consultant, or other person under contract with the USPS to fulfill an agency function; to the Federal Records Center for storage; to the Office of Management and Budget for review of private relief legislation; to an independent certified public accountant during an official audit of USPS finances; to an investigator, administrative judge or complaints examiner appointed by the Equal Employment Opportunity Commission for investigation of a formal EEO complaint under 29 CFR 1614; to the Merit Systems Protection Board or Office of Special Counsel for proceedings or investigations involving personnel practices and other matters within their jurisdiction; and to a labor organization as required by the National Labor Relations Act. Under the Privacy Act provision, the information requested is voluntary for the complainant, and for Postal Service employees and other witnesses.

A.Use this form to file a formal complaint if you are an employee or applicant who believes that you have been discriminated against by the Postal Service because of your race, color, religion, sex, age (40+), national origin, or disability. You must have presented the matter to an EEO dispute resolution specialist within 45 calendar days of the date the incident occurred or, if a personnel action is involved, within 45 calendar days of the effective date of the action.

B.Unless you have agreed to extend the 30-day period for an additional 60 calendar days, you will receive a notice of right to file a formal complaint within 30 calendar days from the date of your first contact with the EEO Office. You must file your formal complaint within 15 calendar days of the date on which you receive your notice of right to file. If you do not receive a notice of right to file within the appropriate time period, you may file a formal complaint at any time thereafter, up to 15 calendar days after receiving the notice.

C.If you have agreed to participate in alternate dispute resolution (ADR), the informal process must be completed within 90 calendar days of your first contact with the EEO office. You have a right to file a formal complaint at any time thereafter, up to 15 calendar days after you have received your notice of right to file.

D.Your notice of right to file contains the address where your formal complaint must be mailed or delivered. The formal complaint will be deemed timely if it is received or postmarked before the expiration of the 15-day filing period, or, in the absence of a legible postmark, if it is received by mail within 5 days of the expiration of the filing period.

E.The time limits for filing a formal complaint may be extended if you show that you were prevented by circumstances beyond your control from timely submitting the complaint, or if you present other reasons considered sufficient by the Postal Service.

F.If you need help in preparing this form, you may obtain assistance from a representative of your choice. You may also seek guidance from the dispute resloution specialist who issued you the notice of right to file.

G.Your formal complaint must be in writing and must be signed and dated by you or your attorney. You are entitled to a representative of your choice at all stages of the EEO complaint process; however, only an attorney can sign official EEO documents on your behalf.

H.If your written complaint is accepted, it will be assigned to an EEO complaints investigator who will provide you with an opportunity to present all facts that you believe resulted in the alleged discrimination. The EEO complaints investigator will conduct a thorough review of the circumstances under which the alleged discrimination occurred.

I.While your complaint is under investigation, you may amend it to add claims that are like or related. Contact the EEO office for the address where your written amendment request must be mailed or delivered.

J.You or your representative will each be provided a copy of the completed investigative file. You have the right to request a hearing within 30 calendar days of of the date you receive the investigative file by mailing or delivering your request to the appropriate Equal Employment Opportunity Commission (EEOC) District Office with a copy to the area Manager, EEO Compliance & Appeals. If you are represented by an attorney, the 30-day period will begin on the date

your attorney receives a copy of the case file. Instead of requesting a hearing, you may request an agency decision without a hearing and the head of the agency or his/her designee will issue you a decision letter with appeal rights.

K.If you request a hearing, the EEOC will appoint an administrative judge (AJ) to conduct a hearing. The AJ will notify you and the Postal Service of the right to seek discovery prior to the hearing to develop evidence reasonably on matters relevant to the issues raised in the complaint(s) to be heard. Attendance at the hearing will be limited to persons the administrative judge determines have direct knowledge relating to the complaint. Hearings are part of the investigative process and are closed to the public.

L.Following the hearing, the AJ will send you and the agency a copy of the hearing record, including the transcript and his/her decision. The head of the agency, or his/her designee, will review the entire record, including the transcript, and will determine whether or not to implement the AJ’s decision. You will receive the agency’s notification of final action within 40 days of the date the agency receives the AJ’s decision. If the agency’s final action will not fully implement the AJ’s decision, the agency must appeal to the EEOC. A copy of the Postal Service’s appeal will be attached to your notification of final action.

M.If you are not satisfied with the decision of the AJ, or the agency’s final action on the decision, you have the right to appeal within 30 calendar days after receiving notification of the agancy’s final action. Your appeal must be mailed to the EEOC at the following address:

EEOC

OFFICE OF FEDERAL OPERATIONS

PO BOX 19848

WASHINGTON DC 20036-9848

N.Instead of filing an appeal of the agency’s final action to the EEOC’s Office of Federal Operations (OFO), you may file a civil action in an appropriate U.S. District Court within 90 calendar days of your receipt of the agency’s final action.

O.You may also file a civil action in an appropriate U.S. district court: after 180 calendar days have passed from the date you filed the complaint, if the final agency action has not been issued and an appeal has not been filed; within 90 days of receipt of the OFO’s decision on your appeal; or after 180 days have passed from the date you filed your appeal with the OFO, if there has been no decision issued on that appeal.

P.Special statutory provisions in the Age Discrimination in Employment Act of 1967, as amended, 29 U.S.C. § 633a, relate to age discrimination. The Public Law sets forth the right to by-pass the administrative complaint processing procedure and file a civil action. For additional information, contact the EEO office.

Q.Under the Equal Pay Act, you have the right to file a civil action without exhausting the administrative procedures.

R.You must keep the EEO complaint processing office aware of your current mailing address at all times. Failure to notify the EEO complaint processing office and the EEOC of an address change could result in the dismissal of your complaint.