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Federal Communications Commission
OMB 3060-1237
Office of Workplace Diversity
Estimated Time Per
Response:
3.51 Hours
draft
INITIAL CONTACT and/or COUNSELING SESSION
for INFORMAL COMPLAINT of DISCRIMINATION
PRIVACY ACT STATEMENT: 1. AUTHORITY - The authority to collect this information is derived from 42 U.S.C. § 2000e-16;
29 C.F.R. §§1614 .106, 1614.108. 2. PURPOSE AND USE - This information will be used to document the issues and
allegations of a complaint of discriminaton based on race, color, sex (including sexual harassment), religion, national origin
age, disability (physical or mental), genetic information, or reprisal. The signed statement will serve as the record necessary
to initiate an investigation and will become part of the complaint file during the investigation or hearing, if any; adjudication
and appeal, if one, to the Equal Employment Opportunity Commission . 3. EFFECTS OF NON - DISCLOSURE - Submission
of this information is MANDATORY. Failure to furnish this information will result in the return of the complaint without action.
1. NAME (Last, First, Middle Initial)
2. ARE YOU A(N):
Employee
3a. HOME PHONE NO.
3c. MOBILE PHONE NO.
3b. WORK PHONE NO.
Former Employee
Applicant
3d. ADDRESS (Include City, State, and Zip Code)
3e. PRIMARY EMAIL
3f. SECONDARY EMAIL
4. ADDRESS OF YOUR CURRENT POSITION
5. TITLE AND GRADE OF YOUR CURRENT POSITION
6a. NAME OF INDIVIDUAL(S) YOU BELIEVE DISCRIMINATED AGAINST YOU
6b. DATE ON WHICH MOST RECENT ALLEGED DISCRIMINATION
OCCURRED
6c. SPECIFY BUREAU/OFFICE/DIVISION OF INDIVIDUAL(S) NAMED IN 6a.
7. REASON YOU BELIEVE YOU WERE DISCRIMINATED AGAINST (Check Below).
a. RACE (State your Race)
f. AGE
_
b. COLOR (State your Color)
(Specify your Age)
g. DISABILITY
_
Mental
c. RELIGION (State your Religion)
_
Physical
h. GENETIC INFORMATION:0
Family Medical History
d. SEX
Female
Male
Orientation
Gender Identity
Genetic Testing
Genetic Services
i. REPRISAL
e. NATIONAL ORIGIN (State your National Origin)
8. ISSUES IN THE COMPLAINT (CHECK APPROPRIATE BOX/BOXES)
Accommodation (Medical)
Accommodation (Religious)
Assignment of Duties
Awards
Demotion
Reinstatement
Duty Hours
Removal
Evaluation/Appraisal
Reprimand
Harassment
Non-sexual
Retirement
Sexual
Detail
Non-selection
Disciplinary Warnings
Reassignment
Suspension
Terms/Conditions of Employment
Training
Other
Telework
Termination
FCC 5621
Month 2022 - Page 1
INITIAL CONTACT and/or COUNSELING SESSION
for INFORMAL COMPLAINT of DISCRIMINATION
9. 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.) Use additional sheets if necessary.
10. 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.)
11. THE EEO COUNSELOR DISCUSSED THE FOLLOWING SUBJECT AREAS IN THE COMPLAINT PROCESS AND/OR ALTERNATE DISPUTE
RESOLUTION (ADR) PROGRAM WITH THE EMPLOYEE/FORMER EMPLOYEE/APPLICANT AND/OR HANDOUTS WERE PROVIDED.
a. The Role of the EEO Counselor
g. 45-Day Requirement to Contact EEO Counselor
b. The Individual or Class Complaint Process
h. Notify EEO Office of Attorney/Non-Attorney Representative
c. The Basis(es) to File a Complaint (Informal/Formal/Class)
i. Formal Stage Requirement of Attorney to Submit Billing Data
d. The Right to File a Complaint
j. Witness(es) Rights
e. Avenues of Redress
k. ADR Program
f. Rights and Responsibilities
l. Informal Complaint Process
12. THE EMPLOYEE/FORMER EMPLOYEE/APPLICANT ELECTS THE FOLLOWING OUTCOME:
a. Traditional Counseling
b. ADR
Yes
Yes
No
No
c. Declined to Pursue Matter Under Title VII
d. Remain Anonymous
Yes
Yes
No
No
14. DATE OF THIS COUNSELING SESSION
13. SIGNATURE OF EMPLOYEE/FORMER EMPLOYEE/APPLICANT
(Month, Day, Year)
DATE OF COUNSELING SESSION
NAME OF EEO COUNSELOR
SIGNATURE OF EEO COUNSELOR
Page 2
FCC 5621
Month 2022 - Page 2
FCC NOTICE REQUIRED BY THE PAPERWORK REDUCTION ACT
We have estimated that each response to this collection of information will take 3.51 hours. Our estimate includes th<:
time to read the instructions, look through existing records, gather and maintain the required data, and review the fom
or response. Ifyou have any comments on this estimate, or on how we can improve the collection and reduce the
burden it causes you, please write the Federal Communications Commission, AMD-PERM, Paperwork Reduction
Project (3060-1237), Washington, DC 20554. We will also accept your comments via the Internet if you send them
to pra@fcc.gov. Please DO NOT SEND COMPLETED APPLICATIONS TO THIS ADDRESS. Remember you are not required to respond to a collection of information sponsored by the Federal government, and the
government may not conduct or sponsor this collection, unless it displays a currently valid OMB control number or if
we fail to provide you with this notice. This collection has been assigned an OMB control number of 3060-1237.
THE FOREGOING NOTICE IS REQUIRED BY THE PAPERWORK REDUCTION ACT OF 1995,
P.L. 104-13, OCTOBER 1, 1995, 44 U.S.C. 3507
FCC 5621
Month 2022 - Page 3
File Type | application/pdf |
File Modified | 2022-11-30 |
File Created | 2022-07-07 |