Notice to EEO Counselor: This report must be completed for each counseling instance. When a formal complaint is filed, the report must be completed within 15 days after notification that a formal complaint has been received. The information in this report should be specific and clear in describing the allegations, dates, inquiries, and informal resolution efforts made.

EEO Counseling Report Form: December 1998

Note: Attach all relevant documents and supplemental sheets, including but not limited to a:

  1. Copy of the Rights and Responsibilities for Processing Complaints of Discrimination and/ or complaints filed pursuant to 373 DM Chapter 7, signed by the aggrieved person , including the certificate of receipt, if mailed.       

  2. Copy of the Notice of Final Interview signed by the aggrieved person , including a copy of the certificate of receipt, if mailed.       

  3. Copy of any informal resolution agreement(s) presented to the aggrieved person for acceptance/rejection.      

  4. Copy of the Agreement to Extend the Counseling Period, if an extension was approved.

    BUREAU: ___________________________________________________________

    EEO COUNSELOR'S NAME: ___________________________________________

    LOCATION: ____________________________TELEPHONE: _________________





    PART A

    1. Aggrieved Person 's Full Name:


        Home Phone:

    2. Place of Employment:


        Work Phone:

        Position, if working for Federal Government:

        Position Title, Series, Grade

    3. Office Where Complaint Arose, if different from above:


    4. Anonymity Requested
: (mark one) Yes No

    5. Aggrieved Person 's Representative:



        Attorney Non-Attorney

    6. Aggrieved Persons Initial Contact with EEO Official (Date):

    7.    EEO Counselors Initial Interview with Aggrieved Person (Date):

    8. Regional Equal Opportunity Manager Advised of Complaint (Date):

    When providing alternate counseling, Bureau EEO Officer/EEO Manager advised of Complaint (Date):

    9. Notice of Rights and Responsibilities for Processing Complaints of Discrimination Issued  (Date):

    9 A. Notice of Rights and Responsibilities for Processing Complaints of Discrimination pursuant to 373
            DM Chapter 7 Issued (Date):

    10. Notice of Final Interview (NOFI): Date hand delivered:

        Date Sent and Certified Mail number:

    (Note: The NOFI also must be sent to the representative if the aggrieved person has designated one)

    11. Notice of Final Interview Received by Aggrieved Person (Date): .

        (If the Notice of Final Interview was mailed, attach the certified mail return receipt card [green card]).

    12. Agreement to Extend Counseling Period

        a. Date on which Agreement to Extend Counseling Period was Signed:

        b. Date to which Counseling Period was Extended:



  1. Alleged Discriminatory Basis (Be specific. For example, if "Age," give the date of birth):   
Race: Color:
Sex: Religion:
Age: National Origin:
Mental Disability:
Physical Disability
Sexual Orientation:
Reprisal: If in connection with the employee's prior complaint activity, indicate whether an informal or formal complaint was pursued. If the individual filed a formal complaint(s), provide the Docket Number(s): . If the prior EEO activity was unrelated to the individual's complaint, describe the EEO activity the individual participated in (i.e., served as a witness in the investigation of X complaint; objected to a discriminatory comment made by X in Y month, Z year, etc.).

Other: (Matter not covered by Federal EEO complaint regulations under 29 C.F.R. 1614 - Also See Part E.3. and DM 373 Chapter 7
  1. Alleged Discriminatory Matter(s)/Action(s): NOT CLEAR.
For each allegation, separately state the bases, the specific incident, and the date of the incident. (For example, the aggrieved person alleges discrimination based on age (over 40) when he/she became aware on March 15, 1997, that she/he was not promoted to the position of Park Ranger, GS-5, advertised in Vacancy Announcement Number xxxx. After identifying the allegation, explain why or how the aggrieved person believes he/she has been harmed.)

Date of 45th Day After Last Incident: (calendar days)
  1. If any incidents occurred more than 45 days before initial contact, record the individual's reason(s) why (s)he did not raise the matter earlier?
In what manner was the aggrieved person made aware of the discrimination complaint procedures, including the time limit in which to contact an EEO Counselor? (Record your observations as to where EEO posters are displayed or the manner in which employees/applicants are made aware of the discrimination complaint procedures. For example, state if the office displays a poster on its official bulletin board identifying the name, location, and phone numbers of the EEO Counselors. Describe if the poster includes a notice of the requirement to contact an EEO Counselor and the time limits for doing so. Include a copy of the certificate of posting [copy attached] )
  1. Corrective Action Sought by and Discussed with Aggrieved person: (Describe the relief/remedies requested by the aggrieved person. Indicate if the aggrieved person is seeking compensatory damages).


Summary of Informal Inquiry: (Describe the facts gathered. Do not express an opinion as to the merit of the complaint.)
  1. Witness Interviews. (Identify each witness interviewed giving their full name, position title, protected group status as it relates to the alleged discriminatory bases and the date of the interview. Summarize each witness interview.)   

  2. Document Review. (Identify the documents reviewed, including the date of the documents. Copies of the documents may be included).

  3. Survey of Environment. (In order to identify similarly situated employees, describe the make- up of the organizational unit by name, position title, and the protected status of the employees relative to the bases of the complaint. For example, if sex discrimination is alleged, identify the employees in a similar position as the aggrieved person who report to the same Division Chief and identify their gender.

    PART D

  1. Was the Aggrieved Person advised of the availability of Alternative Dispute Resolution (ADR)? Yes____ No____
Was resolution sought through an ADR process or through the informal EEO counseling process?
         Informal EEO Counseling: _____ ADR: _____

         Was the matter resolved? Yes ___ No ___

         Explain, if no.

    PART E

  1. Has the aggrieved person filed a grievance related to the issue(s) identified under B.2?
Yes _____________Date grievance filed:_________________ No _________
If yes, attach a copy of the grievance.


  1. Has the aggrieved person filed an appeal with the Merit Systems Protection Board about the issue(s) raised under B.2?
Yes___________ Date appeal filed:_______________________ No ________
If yes, attach a copy of the appeal.

  1. Non-EEO Matter - If the aggrieved person alleged discrimination related to a matter not covered by Title VII of the Civil Rights Act, the Age Discrimination in Employment Act, the Equal Pay Act, or the Rehabilitation Act, i.e., on sexual orientation, a negotiated grievance matter, etc., identify the office to which aggrieved person was referred and the date of the referral.):

  1. Management Notification/Contacts:
Was management advised of the informal and formal EEO complaint process?

Yes_____ No_____

Was management notified of the allegations? Yes_____ No_____

Was management notified of the conclusion of EEO counseling? Yes_____ No_____

  1. ATTACHMENTS (List and describe each attachment to the Report of Counseling, including any information given to the aggrieved person.)
  1. Rights and Responsibilities for Processing Complaints of Discrimination, signed by aggrieved person or certificate of receipt; and/or:

  2. Rights and Responsibilities for Processing Complaints of Discrimination pursuant to 373 DM 7, signed by aggrieved person or certificate of receipt.      

  3. Notice of Final Interview and Right to File a Discrimination Complaint, signed by aggrieved person and certificate of receipt.       

  4. Agreement to Extend EEO Counseling.



This statement certifies that the __(BUREAU)__, __RESERVATION/FIELD STATION__,__LOCATION__, has notified all employees of the names, business telephone numbers and business addresses of its EEO Counselors. This notice has been posted prominently and conspicuously at __[IDENTIFY AND DESCRIBE LOCATION(s) OF POSTER(s)__].

[Also describe other mechanisms used for notifying employees of the names, locations, and telephone numbers of the counselors, and the time frames for contacting a counselor , e.g. Bulletin Boards, LAN, orientation packages for new employees etc.]

The notice also specifies that applicants and employees alleging prohibited discrimination on the basis of race, color, age, sex, national origin, religion and physical and mental handicap or sexual orientation must contact an EEO Counselor within 45 days of the alleged discriminatory action or event before filing a complaint. The telephone numbers and addressees of the EEO Director, EEO Officers and Special Emphasis Program Managers are also listed.

The undersigned certify that the __(BUREAU)__,__(REGION)__, has met the posting requirements of 29 C.F.R. 1614.102 (b)

    ______________________ ________________________

    Management Official          EEO Officer

    ______________________ _____________________

    Date                                      Date
1. The information contained in this report is subject to the non-disclosure provisions of the Privacy Act of 1974, Public Law 93-579, 5 U.S.C. 552a. A copy of this report should be given to the aggrieved person after he/she files a formal complaint.