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What agency is your claim against?*
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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?*
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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?
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- Actually taken
Date of proposal
Date Format: MM slash DD slash YYYY
Date of notification
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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
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What is the basis of the discrimination?
- Sex
- Race
- National Origin
- Color
- Marital Status
- Disability
- Age
- Sexual Orientation
- Religion
- Reprisal
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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?
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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?*
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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?*
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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?
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Date the union was contacted on this matter
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BRIEFLY describe the union's role
Current employment status*
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Date of termination
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