Form TD F 62-03.11 TD F 62-03.11 ADR Election Form

Privacy Act Statement
AUTHORITY: 29 U.S.C. § 206(d); 29 U.S.C. § 791; 42 U.S.C. § 2000e; 42 U.S.C. § 2000ff-(2);
29 U.S.C. § 633a; 5 U.S.C. § 1303-1304; 5 CFR § 5.2-5.3; 29 CFR § 1614.105, .107; Executive
Order 11478, as amended; and Executive Order 13152 and Management Directive 110 (August
2015).
PRINCIPAL PURPOSE(S): This information is being collected for the sole purpose to record a
pre-complaint allegation of employment discrimination with the Department of the Treasury on
the grounds of race, color, religion, sex (including pregnancy), national origin, age, disability,
protected genetic information, parental status, or reprisal. An employee or applicant must
participate in pre-complaint EEO counseling to informally resolve the allegation(s) per §1614.105,
prior to filing a formal EEO complaint of discrimination. The information captured on this form will
be used by the Department of the Treasury to record the election of the aggrieved to continue
with the pre-complaint EEO counseling process or to voluntarily participate in mediation under
the EEO Alternative Dispute Resolution (ADR) process.
ROUTINE USE(S): The information on this form may be disclosed as generally permitted under
5 U.S.C. §552a(b) of the Privacy Act of 1974, as amended. This includes using this information
as necessary and authorized by the routine uses published in system of notice records notice
Treasury .013--Department of the Treasury Civil Rights Complaints and Compliance Review
Files- 81 FR 78266 (Nov. 7, 2016).
PAPERWORK REDUCTION ACT STATEMENT: In accordance with the Paperwork Reduction
Act of 1995, the Department of the Treasury 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
1505-0262. 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 5 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 Department of the Treasury, Office of Civil Rights and EEO, 1500 Pennsylvania
Avenue, N.W., Washington, DC 20220.
TD F 62-03.11
Revised 04/2025

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Department of the Treasury

OMB No. 1505-0262
Expiration Date: 06/30/20XX

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Name of the Counselee: ______________________________
Pre-Complaint Number:

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ALTERNATE DISPUTE RESOLUTION
I fully explained and offered Alternative Dispute Resolution (ADR) to the Counselee.
If available, I provided a copy of the bureau's ADR guide/booklet. I provided the
person in the EEO informal stage with the opportunity to elect between EEO
Counseling and ADR.

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Signature of EEO Counselor

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Date

I elect mediation instead of EEO Counseling

I do not want mediation and wish to continue with EEO Counseling.

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Signature of Counselee

TD F 62-03.11
Revised 04/2025

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Date