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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?
- Proposed
- Actually taken
Date of proposal
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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?
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For example: replied to proposed discipline, filed a grievance, filed an MSPB appeal
What steps?
When taken?
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What is the status?
Are you alleging discrimination?*
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What is the basis of the discrimination?
- Sex
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- Marital Status
- Disability
- Age
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- 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
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When did you conact the EEO counselor within your Agency?
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Have you filed a formal EEO complaint?*
- Yes
- No
When did you file the complaint?
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Have you received a Report of Investigation regarding your formal complaint?
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Date the report was received
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Have you requested a hearing before an EEOC Administrative Judge?
- Yes
- No
Date the request was filed
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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
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?
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
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BRIEFLY describe the union's role
Current employment status*
- Working
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Date of termination
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Date of suspension
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