Name* First Last Home PhoneWork PhoneCell PhoneEmail* Enter Email Confirm Email Referred byWhat agency is your claim against?*Please specify what department it is organized under.Position*Salary*Grade*How long have you worked at that agency?*How long have you worked for the federal government?*Are you being subject to a personnel action?* Yes No For example: leave restriction, denial of promotion, suspension, removalDescribe the personnel actionHas the personnel action described above been merely proposed or actually taken? Proposed Actually taken Date of proposal MM slash DD slash YYYY Date of notification MM slash DD slash YYYY of decision actually takenBRIEFLY describe the agency's stated reason for taking the personnel actionHave you taken any steps to formally challenge the agency's action? Yes No For example: replied to proposed discipline, filed a grievance, filed an MSPB appealWhat steps?When taken? MM slash DD slash YYYY What is the status?Are you alleging discrimination?* Yes No What is the basis of the discrimination? Sex Race National Origin Color Marital Status Disability Age Sexual Orientation Religion Reprisal Other If "Other", please describeBRIEFLY describe the events which you believe were discriminatory:Have you contacted an EEO counselor within your agency?* Yes No When did you conact the EEO counselor within your Agency? MM slash DD slash YYYY Have you filed a formal EEO complaint?* Yes No When did you file the complaint? MM slash DD slash YYYY Have you received a Report of Investigation regarding your formal complaint? Yes No Date the report was received MM slash DD slash YYYY Have you requested a hearing before an EEOC Administrative Judge? Yes No Date the request was filed MM slash DD slash YYYY What is the current status?For example: Have you received any orders from the judge? Has a hearing date been set?Have you begun any proceeding in any federal court related to the claim you are contacting us about?* Yes No Date the request was filed MM slash DD slash YYYY What is the current status?For example: Have you received any orders from the judge? Has a hearing date been set?Are you facing any deadlines related to ANY of the above claims?* Yes No What is the date of the deadline? MM slash DD slash YYYY What is due by the deadline?Are you covered under a union contract?* Yes No Name and Local No. of unionHave you requested the union's assistance with your problem, or has the union intervened on your behalf? Yes No Date the union was contacted on this matter MM slash DD slash YYYY BRIEFLY describe the union's roleCurrent employment status* Working On administrative leave Terminated Suspended Date of termination MM slash DD slash YYYY Date of suspension MM slash DD slash YYYY If an attorney cannot call you back within normal business hours, what is the latest time an attorney can call you at home?*CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
