VA Form 4939 at a glance
What it is: VA Form 4939 is the Complaint of Employment Discrimination, OMB No. 2900-0716.
Where and when to file: The complaint should be filed with the ORMDI District Office identified in the NRTF.
Pursuant to the Equal Employment Opportunity Commission (EEOC) Title 29 Code of Federal Regulations (29 C.F.R.) §1614, VA Form 4939, Complaint of Employment Discrimination, can be used by VA employees, former employees and applicants for employment who file a formal Equal Employment Opportunity (EEO) complaint of discrimination.
A filled-in VA Form 4939 example: a VA employee files a complaint
How to fill out VA Form 4939, box by box
Your name, email address and telephone numbers
1. Name: last, first, middle initial. Please print.
2. Email address.
3. Mailing address. 4a. Work telephone number, including area code.
4b. Primary telephone number, including area code.
Are you, your job and the VA facility
5. Are you a VA employee, an applicant for employment or a former VA employee?
6a. Job title, series and grade.
6b. Service/section/product line.
7. Name and address of VA facility where discrimination occurred.
Bases, claim(s), date of occurrence and remedies sought
For each employment related matter that you believe was discriminatory you must list the bases: Race (Specify), Color (Specify), Religion (Specify), Sex (Male, Female, Sexual Orientation, Gender Identity, including, but not limited to, Transgender), National Origin (Specify), Age (Provide date of birth), Disability (Specify), Genetic Information (including family medical history), and/or Reprisal for participating in the EEO process or opposing unlawful discrimination.
If you list "Reprisal," please state the nature of the prior EEO activity in which you were engaged, i.e. did you file a prior EEO complaint?
9. Claim(s): briefly state the specific claim, personnel action and/or event that caused you to file this complaint. Use an additional sheet of paper if necessary. You should not include information that violates the Privacy Act of 1974 and the Health Insurance Portability and Accountability Act (HIPAA).
10. Date of occurrence: include the most recent date(s).
It is very important that you be precise as to the dates of all actions or events you are protesting.
11. Remedies sought.
Your representative
12a. Do you have a representative?
12b. If "YES," is he or she an attorney?
12c. Provide the name and address of your representative.
12d. Telephone number, including area code.
12e. Email address.
You may have a representative of your own choosing at all stages of the processing of your complaint.
No EEO Counselor, EEO Investigator or EEO Officer may serve as a representative.
The EEO Counselor and untimely filing
13a. Have you contacted an EEO Counselor?
13b. Name of EEO Counselor. 13c. Date of initial contact with ORM.
14. If you contacted an EEO Counselor more than 45 calendar days after the Date(s) of Occurrence, listed in item 10, or if this complaint is filed more than 15 calendar days after receipt of a Notice of Right to File a Discrimination Complaint, you must explain why you were untimely in seeking EEO counseling or untimely in filing a complaint.
In addition, the claims listed in item 9, must be limited to those claims discussed with an EEO Counselor (discussed within 45 calendar days of occurrence of the event, or within 45 calendar days of the effective date, if a personnel action) or like or related claims.
If any of the claims listed in item 9 were discussed with an EEO Counselor, but not within 45 calendar days of their occurrence or of their effective date, you must explain why you waited more than 45 calendar days.
If any of the claims listed in item 9 were not discussed with an EEO Counselor, please contact the Office of Resolution Management, Diversity and Inclusion (ORMDI), Regional EEO Officer IMMEDIATELY.
The requirement that you contact an EEO Counselor about every claim listed in item 9 will not be waived under any circumstances.
Failure to do so will only delay the processing of your complaint.
Union grievance, MSPB appeal and this complaint filed with anyone else
15a. Have you filed a union grievance on any claim(s) listed?
15b. If "YES," list the claim(s) and date grievance filed.
16a. Have you filed an appeal with the Merit System Protection Board (MSPB) on any of the claims listed?
16b. If "YES," list the issue(s) and date MSPB appeal filed.
17a. Have you filed this complaint with anyone else?
17b. If "YES," provide the name and address.
Signature and date
18. Signature of complainant: sign in ink. Do not print. 19. Date.
Your representative need not be an attorney, but only an attorney representative may sign the complaint on your behalf.
More rules for VA Form 4939
Please complete all items on the complaint form.
You can obtain assistance from your EEO Counselor in filling out this form.
Your EEO Counselor can also answer any questions you may have about this form.
It is your responsibility to keep the ORMDI informed of your current address.
These time limits may be extended under certain circumstances; however, they will NOT be waived and your complaint will NOT be investigated unless you explain your untimeliness and the explanation is acceptable in accordance with EEOC, 29 C.F.R. §1614(c).
If you move, immediately advise the ORMDI District Office where you filed this complaint of your new address.
It is your responsibility to claim all certified and express mail.
Failure to notify ORMDI of a change in address or to claim certified and express mail may lead to dismissal of your complaint.
Supersedes VA Form 4939, MAR 2017, which should not be used.
Common questions about VA Form 4939
Is there a deadline?
Your formal complaint must be filed within 15 calendar days of the date you received the "Notice of Right to File a Discrimination Complaint" (NRTF) from your EEO Counselor. If you do not meet this time limit, you must explain why you waited more than 15 calendar days to file.
Where do I file it?
The complaint should be filed with the ORMDI District Office identified in the NRTF. You may submit a copy either by mail, in person, electronically (via e-mail), or by facsimile. Filing instructions are contained in the cover letter attached to the NRTF.
Sources
[1] VA Form 4939 (JUL 2020), Complaint of Employment Discrimination, Department of Veterans Affairs (the Official source link on this page).