Form FCC Form 5622 FCC Form 5622 FORMAL COMPLAINT OF DISCRIMINATION

Federal Communications Commission
Office of Workplace Diversity OMB Control No. 3060-1237
Estimated Time Per Response: 3.5 hours
[Month] 2022

FORMAL COMPLAINT OF DISCRIMINATION
1. NAME OF COMPLAINANT (Last, First, Middle Initial)

2. COMPLAINT TYPE
Initial

3a. HOME PHONE NO.

3b. WORK PHONE NO.

3d. PRIMARY EMAIL

3c. MOBILE PHONE NO.

Class

Amendment

4. ADDRESS (Include City, State, and ZIP Code)

3e. SECONDARY EMAIL

5a. ARE YOU BEING REPRESENTED?

5c. ADDRESS, PHONE NUMBER AND EMAIL OF REPRESENTATIVE

a. Yes (Complete 5b and 5c)

b. No

5b. IF YES, NAME OF REPRESENTATIVE
6a. ARE YOU CURRENTLY A FEDERAL EMPLOYEE
a. Yes (Complete 6b and 6c)

6c. ADDRESS OF YOUR CURRENT POSITION

b. No

6b. TITLE AND GRADE OF YOUR CURRENT POSITION

7. DATE ON WHICH MOST RECENT ALLEGED DISCRIMINATION
OCCURRED

8a. NAME OF INDIVIDUAL(S) YOU BELIEVE DISCRIMINATED AGAINST YOU

8b. SPECIFY BUREAU/OFFICE/DIVISION OF INDIVIDUAL(S) NAMED
IN 8a.

9. REASON YOU BELIEVE YOU WERE DISCRIMINATED AGAINST (Check Below).
a. RACE (State your Race) ___________________

g. AGE

b. COLOR (State your Color) ___________________

h. DISABILITY
Mental

c. RELIGION (State your Religion) ___________________

(Specify Age) _____

i. GENETIC INFORMATION:
Family Medical History

d. SEX

Female

Male

Orientation

Physical

Gender Identity

Genetic Testing
Genetic Services

k. REPRISAL

e. PREGNANCY ___________________
f. NATIONAL ORIGIN (State your National Origin) ___________________

10a. I HAVE DISCUSSED MY COMPLAINT WITH AN EQUAL EMPLOYMENT OPPORTUNITY (EEO) COUNSELOR AND/OR OTHER EEO OFFICIAL
Date of First Contact with EEO Office: _________________________
10b. NAME OF EEO COUNSELOR: ____________________________

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FORMAL COMPLAINT OF DISCRIMINATION
10c. DATE OF INITIAL INTERVIEW: _________________
10d. DATE OF RECEIPT OF NOTICE OF FINAL INTERVIEW WITH EEO COUNSELOR/RIGHT TO FILE: __________________
11. EXPLAIN SPECIFICALLY HOW YOU WERE DISCRIMINATED AGAINST (Explain how you were treated differently from other employees, former
employees or applicants, because of your race, color, religion, sex, national origin, age, mental or physical handicap, genetic information, or
reprisal.) (If your complaint involves more than one basis for your dissatisfaction, list and number each such allegation separately and furnish
specific, factual information in support of each allegation.) Attach additional sheets, if necessary.

12. WHAT SPECIFIC ACTION DO YOU WANT TAKEN TO RESOLVE YOUR COMPLAINT? (If more than one allegation is being made, state overall
corrective action desired and the specific corrective action desired for each separate allegation.)

13. LIST THE NAMES OF YOUR WITNESSES AND THE FACTUAL INFORMATION EACH WITNESS WILL BE EXPECTED TO CONTRIBUTE
THROUGH HIS/HER TESTIMONY TO THE INVESTIGATION OF YOUR COMPLAINT.

14a. HAS/HAVE THE MATTER(S) LISTED IN ITEM 12 BEEN APPEALED TO THE MERIT SYSTEM PROTECTION BOARD OR FILED UNDER THE
NEGOTIATED GRIEVANCE PROCEDURE?

Yes

No

14b. If yes, provide date of appeal or filing and attach a copy of the appeal or filing _______________________

15. REMARKS (Use space to provide additional information)

17. DATE OF THIS COMPLAINT (Month, Day, Year)

16. SIGNATURE OF COMPLAINANT

DATE RECEIVED IN EEO OFFICE

NAME OF EEO REPRESENTATIVE

SIGNATURE OF REPRESENTATIVE

FCC Form 5622

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PRIVACY ACT STATEMENT:
1. Authority: 42 U.S.C. § 2000e-16; 29 CFR § 1614 et seq; 47 CFR § 0.81.
2. Purpose: These records are maintained for the purpose of counseling, investigating and
adjudicating complaints of employment discrimination brought by applicants and current and
former federal employees against federal employers.
3. Routine Uses: Information contained in this form is available to other individuals when
necessary and appropriate under 5 U.S.C. § 552a(b) of the Privacy Act, including: to the
appropriate federal, state, or local agency responsible for investigating, prosecuting, enforcing,
or implementing a statute, rule, regulation, or order, where the disclosing agency becomes
aware of an indication of a violation or potential violation of civil or criminal law or regulation; to
another federal agency, to a court, or to a party in litigation before a court or in an
administrative proceeding being conducted by a federal agency when the government is a
party to the judicial or administrative proceeding; to a congressional office from the record of an
individual in response to an inquiry from that congressional office made at the request of that
individual; to an authorized appeal grievance examiner, formal complaints examiner,
administrative judge, equal employment opportunity investigator, arbitrator or other duly
authorized official engaged in investigation or settlement of a grievance, complaint or appeal
filed by an employee; in response to a request for discovery or for appearance of a witness,
information that is relevant to the subject matter involved in a pending judicial or administrative
proceeding; to officials of state or local bar associations or disciplinary boards or committees
when they are investigating complaints against attorneys in connection with their
representation of a party before EEOC; to a Federal agency in the executive, legislative, or
judicial branch of government, in response to its request information in connection with the
hiring of an employee, the issuance of a security clearance, the conducting of a security or
suitability investigation of an individual, the classifying of jobs, or the lawful statutory,
administrative, or investigative purpose of the agency to the extent that the information is
relevant and necessary to the requesting agency's decision; to employees of contractors
engaged by an agency to carry out the agency's responsibilities under 29 CFR part 1614; to
potential witnesses as appropriate and necessary to perform the agency's functions under 29
CFR part 1614; to facilitate statistical research, audit or investigative matters; and, to
appropriate agencies, entities, and persons when the FCC suspects or has confirmed that
there has been a breach of information related to OWD.
4. Disclosure: Submission of this information is voluntary; however, failure to furnish this
information will result in the return of the complaint without action.

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