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Referred by
What 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, removal
Describe the personnel action
Has the personnel action described above been merely proposed or actually taken?
- Proposed
- Actually taken
Date of proposal
Date Format: MM slash DD slash YYYY
Date of notification
Date Format: MM slash DD slash YYYY

of decision actually taken
BRIEFLY describe the agency's stated reason for taking the personnel action
Have 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 appeal
What steps?
When taken?
Date Format: 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 describe
BRIEFLY 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?
Date Format: MM slash DD slash YYYY
Have you filed a formal EEO complaint?*
- Yes
- No
When did you file the complaint?
Date Format: MM slash DD slash YYYY
Have you received a Report of Investigation regarding your formal complaint?
- Yes
- No
Date the report was received
Date Format: MM slash DD slash YYYY
Have you requested a hearing before an EEOC Administrative Judge?
- Yes
- No
Date the request was filed
Date Format: 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
Date Format: 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?
Date Format: 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 union
Have 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
Date Format: MM slash DD slash YYYY
BRIEFLY describe the union's role
Current employment status*
- Working
- On administrative leave
- Terminated
- Suspended
Date of termination
Date Format: MM slash DD slash YYYY
Date of suspension
Date Format: 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?*
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With well over 50 years of combined experience in federal employment, we can talk to you intelligently about your federal employment problem. If your career is on the line, go with the attorneys who have been there before with other federal employees.

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Bonney, Allenberg & O’Reilly, P.C. is committed to helping federal employees protect their rights. Our focus is on helping working people obtain a workplace that is free of discrimination and fair to all.

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