Form 4939 Complaint of Employment Discrimination

OMB NO.: 2900-0716
EXPIRATION DATE: MAY 31, 2018
RESPONDENT BURDEN: 30 Min.

COMPLAINT CASE NUMBER:

COMPLAINT OF EMPLOYMENT DISCRIMINATION
Read the instructions on the reverse side of this form carefully before completing the front of this form.
1. NAME (Last, first, middle initial)(Please print)

3. MAILING ADDRESS

4a. WORK TELEPHONE NUMBER
(Include Area Code)

2. EMAIL ADDRESS

4b. PRIMARY TELEPHONE NUMBER
(Include Area Code)

6a. JOB TITLE, SERIES AND GRADE

5. ARE YOU:

7. NAME AND ADDRESS OF VA FACILITY WHERE
DISCRIMINATION OCCURRED

A VA EMPLOYEE
AN APPLICANT FOR EMPLOYMENT 6b. SERVICE/SECTION/PRODUCT LINE
A FORMER VA EMPLOYEE

NOTE: For each employment related matter that you believe was discriminatory you must list the bases (list one or more of the following):
Race (Specify), Color (Specify), Religion (Specify), Sex (Male or Female), 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.
9. CLAIM(S)
(What employment related claim(s) - personnel action(s), incident(s), or event(s) caused you to file this complaint?
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). Some examples are patient medical
records, personal records of other VA-employees, etc.)

8. BASIS

10. DATE OF
OCCURRENCE
(Include the most
recent date(s))

11. REMEDIES SOUGHT (Use an additional sheet of paper if necessary.)

12a. DO YOU HAVE A REPRESENTATIVE?
YES

12c. PROVIDE THE NAME AND ADDRESS OF YOUR
REPRESENTATIVE

12d. TELEPHONE NUMBER
(Include Area Code)

NO
12e. EMAIL ADDRESS

12b. IF "YES," IS HE OR SHE AN ATTORNEY?
YES

NO

13a. HAVE YOU CONTACTED AN EEO
COUNSELOR?
YES

13b. NAME OF EEO COUNSELOR

13c. DATE OF INITIAL
CONTACT WITH ORM

NO

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. (Use an additional sheet of paper, if necessary.)
15a. HAVE YOU FILED A UNION
GRIEVANCE ON ANY CLAIM(S)
LISTED ABOVE?
YES

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
ABOVE?

NO

YES

16b. IF "YES," LIST THE ISSUE(S)
AND DATE MSPB APPEAL FILED.

NO

17a. HAVE YOU FILED THIS COMPLAINT 17b. IF "YES," PROVIDE THE NAME AND ADDRESS
WITH ANYONE ELSE?
YES

NO

18. SIGNATURE OF COMPLAINANT (Do not print)

VA FORM
JAN 2017

4939

SUPERSEDES VA FORM 4939, MAR 2013,
WHICH SHOULD NOT BE USED.

19. DATE

COMPLAINT OF EMPLOYMENT DISCRIMINATION INSTRUCTIONS

Read the following instructions carefully before you complete this form. Please complete all items on the complaint form.
GENERAL: 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. This regulation prohibits discrimination based on race, color, religion,
gender (sex), national origin, age (40 years and over), physical or mental disability, genetic information (including family medical history), and/or
reprisal for participating in the EEO process or opposing unlawful discrimination.
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. In item 8, you should specify the basis of your complaint: race, color, religion, gender (sex), national origin, age (date of birth),
physical or mental disability (specific information about your disability), 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? Use an additional sheet of paper, if necessary.
It is very important that you be precise as to the dates of all actions or events you are protesting. 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 (ORM), 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.
It is your responsibility to keep the (ORM) informed of your current address. If you move, immediately advise the ORM District Office where you
filed this complaint of your new address. In addition, you may receive certified and express mail in connection with your complaint. It is your
responsibility to claim all certified and express mail. Failure to notify ORM of a change in address or to claim certified and express mail may lead to
dismissal of your complaint.
REPRESENTATION: 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. (Your representative need not be an attorney, but only an attorney representative
may sign the complaint on your behalf.)
WHEN TO FILE: 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. 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).
WHERE TO FILE: The complaint should be filed with the ORM 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.
PRIVACY ACT STATEMENT: Maintenance and disclosure of VA Form 4939 is made in accordance with the Privacy Act of 1974. Collection
of the information on this form is authorized and/or required by the regulations of the EEOC, 29 C.F.R. §1614. All records, from which information
is retrieved, by the name or personal identifier of a respondent, are maintained by a Government-wide Systems of Records: EEOC/GOVT-1, Equal
Employment Opportunity Complaint Records and Appeal Records. The information collected will be used by ORM to determine whether your
complaint is acceptable for investigation and in connection with any subsequent investigation and processing of your complaint. In the course of any
investigation, this form may be shown to any individual who may be required by regulations, policies or procedures of the EEOC and/or ORM to
provide information in connection with this complaint, including individuals you may have identified as responsible for the acts or events at issue in
this complaint. Other disclosures may be: (a) to respond to a request form from a Member of Congress regarding the status of the complaint or
appeal; (b) to respond to a court subpoena and/or to refer to a district court in connection with a civil suit; (c) to disclose information to authorized
officials or personnel to adjudicate a complaint or appeal; or (d) to disclose information to another Federal agency or to a court or third party in
litigation when the Government is party to a suit before the court.
RESPONDENT BURDEN STATEMENT: In accordance with the Paperwork Reduction Act of 1995, The Department of Veterans Affairs (VA)
may not conduct or sponsor, and the respondent is not required to respond to this collection of information unless it displays a valid OMB Control
Number. The valid OMB Control Number for this information collection is 2900-0716. The collection of this information is voluntary. However,
the information is necessary to determine if your complaint of employment discrimination is acceptable for further processing in accordance with
EEOC, 29 C.F.R. §1614. The time required to complete this information collection is estimated to average 30 minutes per response, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing the form. Send
comments regarding this burden estimate or any other aspects of this collection, including suggestions for reducing this burden, to VA Clearance
Officer (005R1B), 810 Vermont Avenue, Washington, DC 20420. SEND COMMENTS ONLY. DO NOT SEND THIS FORM, A COMPLAINT
OF EMPLOYMENT DISCRIMINATION, OR REQUEST FOR BENEFITS TO THIS ADDRESS

REVERSE OF VA FORM 4939, JAN 2017