Form VA Form 08-10192 VA Form 08-10192 Information for Pre-Complaint Processing

INFORMATION FOR PRE-COMPLAINT PROCESSING
I. REQUESTOR INFORMATION
1. NAME (Last, First, MI)

2. BEST CONTACT TELEPHONE NUMBER

3. MAILING ADDRESS (Street or P.O. Box, City, State, Zip + 4)

5. BUSINESS TELEPHONE NUMBER

4. BUSINESS ADDRESS (Street, City, State, Zip + 4)

6. BEST TIME TO CALL

9. EMPLOYMENT STATUS (Check one)

8. POSITION TITLE/GRADE

TITLE 38

EMPLOYEE

APPLICANT

FORMER EMPLOYEE

OTHER

II. TYPE OF EMPLOYMENT/VA ORGANIZATION

1a.TYPE OF EMPLOYMENT
TITLE 5

7. E-MAIL ADDRESS

2. EMPLOYMENT
FULL TIME
HYBRID 38

3. ORGANIZATION
VHA
NCA

PART-TIME

VBA

5. NAME OF FACILITY

6. FACILITY ADDRESS

1. ARE YOU SES?

2. ARE YOU FILING AGAINST A SES?

YES

NO

OIT

10. SERVICE/SECTION/MAIL CODE

4. BARGAINING UNIT EMPLOYE

CANTEEN
OTHER

YES

NO

7. FACILITY TELEPHONE NUMBER

III. SENIOR EXECUTIVE SERVICE (SES)

YES

NO

IV. DESCRIPTION OF ISSUE(S)/CLAIM(S)

1. USE THE SPACE BELOW TO BRIEFLY DESCRIBE THE ISSUE(S) OR ACTION(S) THAT PROMPTED YOU TO SEEK EEO COUNSELING AT THIS TIME.

On __________________________________, _______, __________
(Month)
(Day)
(Year)

V. DISCRIMINATION FACTORS (BASIS(ES))
Prohibited discrimination includes actions taken based on your Race, Color, Religion, Sex, Age (40 and over), National Origin, Physical and/or Mental Disability, Genetic
Information and/or Retaliation for participating in the EEO process or opposing unlawful discrimination. These categories are referred to on this form as basis(es).
1. WHAT BASIS(ES) OF DISCRIMINATION ARE YOU ALLEGING? (Please be specific, i.e., Race - African American, Sex - Female.)

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FOR RETALIATION ALLEGATIONS ONLY:
2. 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.

a. On __________________________________, _______, __________, I engaged in EEO activity. Case No: __________________________________
(Month)
(Day)
(Year)
b. On __________________________________, _______, __________, I engaged in EEO activity. Case No: __________________________________
(Month)
(Day)
(Year)
VI. COMPARISONS
1. FOR EACH ITEM LISTED IN SECTION IV AND V, PROVIDE WHO YOU BELIEVE YOU WERE TREATED DIFFERENTLY THAN AND WHY.

a. __________________________________________________________
(Name of Employee)
was treated differently than I when:

______________________________________________________________________________
(Basis(es) that describe the employee, i.e., sex (male), National Origin (hispanic))

b. __________________________________________________________
(Name of Employee)
was treated differently than I when:

______________________________________________________________________________
(Basis(es) that describe the employee, i.e., sex (male), National Origin (hispanic))

VII. RESPONSIBLE MANAGEMENT OFFICIAL(S) (RMO)
List the name(s) of the Responsible Management official(s) who took the action(s) which prompted you to seek counseling at this time.
1a. NAME (Last, First, MI)

1b. TITLE

1c. OFFICE

1d. GRADE LEVEL

2a. NAME (Last, First, MI)

2b. TITLE

2c. OFFICE

2d. GRADE LEVEL

3a. NAME (Last, First, MI)

3b. TITLE

3c. OFFICE

3d. GRADE LEVEL

Retaliation Allegations Only:
4. WAS/WERE THE RESPONSIBLE MANAGEMENT OFFICIAL(S) LISTED ABOVE AWARE OF YOUR PRIOR EEO ACTIVITY?
YES (If YES, explain how the official(s) became aware)

NO

VIII. RESOLUTION
1. WHAT ARE YOU SEEKING AS A RESOLUTION TO YOUR PRE-COMPLAINT?

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IX. MERIT SYSTEM PROTECTION BOARD (MSPB) AND NEGOTIATED GRIEVANCE
ON THE ISSUE(S) THAT PROMPTED YOU TO SEEK EEO COUNSELING, HAVE YOU:
1. FILED A UNION GRIEVANCE ON THE ISSUE?

YES

NO

IF YES, DATE

2. FILED AN MSPB APPEAL ON THIS ISSUE?

YES

NO

IF YES, DATE APPEAL FILED:

CURRENT STEP:

X. DOCUMENTATION

Include a copy of any written action(s) that caused you to seek counseling at this time.

XI. PRIVACY ACT STATEMENT

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.
XII. AUTHORIZATION

I am aware that this form will be made part of the official informal complaint record and assigned an Office of Resolution Management (ORM) case number. If
the claim(s) contained herein are like or related to a formal complaint that is currently pending with ORM, prior to issuance of the Advisement of Rights letter, the
District Manager will determine if the claim(s) should be processed as an amendment to the pending formal complaint. You will be notified in writing.
XIII. REPRESENTATION

You have a right to a representative during the EEO complaint process including during EEO counseling. You may select anyone to represent you, as long as their
positon with VA would not represent a conflict of interest. The EEO counselor cannot be your representative.
1.

I DO NOT WANT A REPRESENTATIVE AT THIS TIME. I UNDERSTAND I MAY SELECT A REPRESENTATIVE LATER (or at any stage of the EEO process).
I HAVE A REPRESENTATIVE

2. NAME OF REPRESENTATIVE

3. EMAIL ADDRESS

4. ATTORNEY
YES

5. ADDRESSS

NO

6. TELEPHONE NUMBER

7. FAX NUMBER

XIV. ELECTION TO RECEIVE EEO CORRESPONDENCE VIA EMAIL

Signing the enclosed Election to Receive EEO Correspondence via Email will authorize the Office of Resolution Management (ORM) to send you all documents
electronically.
XV. 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.
PRINT YOUR NAME HERE
YOUR SIGNATURE (Ink signature)

DATE SIGNED

PLEASE RETURN THIS FORM TO:

DEPARTMENT OF VETERANS AFFAIRS
OFFICE OF RESOLUTION MANAGEMENT (08)

ATTN: COUNSELOR TEAM LEADER
EMAIL ADDRESS:

DISCLAIMER: Neither the Department of Veterans Affairs (VA) nor the Office of Resolution Management can guarantee the security of the content of external
emails (emails outside of the `va.gov' domain). Encryption offers protection against unintended readers accessing the content of e-mails. VA provides encryption
services to its employees for intra-agency e-mails and requires its use for email containing sensitive, personal information. Currently, VA does not offer encryption
for email accounts outside of the VA network. If you are concerned with the security of your email transmission, we suggest that you mail this form and any
attachments to the mailing address listed above.
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