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I. REQUIRED ELEMENTS
A. AGGRIEVED PERSON
Name:
Job Title/Series/Grade:________________________________________________
Place of Employment:__________________________________________________
Work Phone No:______________ Home Phone No:________________________
Home Address: ______________________________________________________
________________________________________________________
________________________________________________________
B. CHRONOLOGY OF EEO COUNSELING
Date of Initial Contact:
Date of Initial Interview:______________________________________________
Date of Alleged Discriminatory Event:___________________________________
45th Day After Event:_________________________________________________
Reason for delayed contact beyond 45 days, if applicable:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Date Counseling Report Requested:_____________________________________
Date Counseling Report Submitted:_____________________________________
C. BASIS(ES) FOR ALLEGED DISCRIMINATION
1) [ ] Race (Specify)_______________________________________
2) [ ] Color (Specify)______________________________________
3) [ ] National Origin (Specify)______________________________
4) [ ] Sex (Specify)________________________________________
5) [ ] Age (Date of Birth)___________________________________
6) [ ] Mental Disability (Specify)____________________________
7) [ ] Physical Disability (Specify)___________________________
8) [ ] Religion (Specify)____________________________________
9) [ ] Reprisal (Identify earlier event and/or opposed
practice, give date)__________________________________
D. PRECISE DESCRIPTION OF THE ISSUE(S) COUNSELED
E. REMEDY REQUESTED
F. EEO COUNSELOR'S CHECKLIST - THE COUNSELOR ADVISED THE
AGGRIEVED PERSON IN WRITING OF THE RIGHTS AND
RESPONSIBILITIES CONTAINED IN THE EEO COUNSELOR CHECKLIST.
II. SUMMARY OF INFORMAL RESOLUTION ATTEMPTS
A. IF THE COUNSELOR ATTEMPTED RESOLUTION
1. Personal Contacts
2. Documents Reviewed
3. Summary of Informal Resolution Attempt
B. IF AGGRIEVED OPTED FOR ADR, COUNSELOR'S STATEMENT THAT
THE ADR PROCESS WAS FULLY EXPLAINED TO THE AGGRIEVED
INDIVIDUAL/SUMMARY OF INFORMATION GIVEN TO THE AGGRIEVED
INDIVIDUAL AND THE AGENCY BY THE COUNSELOR
_____________________________ __________________________
Name of EEO Counselor Telephone Number
_____________________________ ___________________________
Signature of Counselor Office Address
_____________________________
Date
This page was last modified on November 8, 1999.