DEPARTMENT OF THE INTERIOR

WASHINGTON, D.C. 20240


DATE:

SAMPLE MEMORANDUM


TO: (Person Counseled)

FROM: (Counselor)

SUBJECT: NOTICE OF FINAL INTERVIEW AND RIGHT TO FILE A DISCRIMINATION COMPLAINT UNDER 29 C.F.R. PART 1614

This memorandum is to inform you that the final counseling interview has been conducted in connection with the matter(s) you presented to me on ____________. Because the matter(s) you brought to my attention has/have not been resolved, you are now entitled to file a discrimination complaint. If you wish to pursue this matter further, and file a formal complaint of discrimination, it must be in writing, signed, and filed, in person or by mail within 15 CALENDAR DAYS AFTER RECEIPT OF THIS NOTICE.

The formal complaint must contain a signed statement that describes what incident(s) occurred, when they occurred, and why you believe you were treated in a discriminatory manner. An incident is a personnel matter or action such as a non-selection, suspension, denied training opportunity, etc. The complaint must encompass only matters raised during counseling. In addition, it must contain the telephone number and address where you may be contacted. The complaint must state whether you filed a grievance under a negotiated grievance procedure or an appeal to the Merit Systems Protection Board on the same matter(s).1

For your convenience, the Department's Individual Complaint Form is attached. Your complaint must be filed with:

Secretary of the Interior
1849 C Street, NW, MS-MIB-6217
Washington, DC 20240

or

Director, Office of Equal Opportunity
Department of the Interior
1849 C Street, NW, MS-MIB-5221
Washington, DC 20240

or

EEO Officer (Bureau Name),
Department of the Interior
Street Address
City, State and Zip Code

or

Regional Complaints Office
Street Address
City, State and Zip Code
Telephone Number


If you file your complaint with one of the listed officials outside the Bureau, please provide a copy of your complaint to the Bureau EEO Officer to ensure prompt processing of your complaint.

If you retain an attorney or any other person to represent you, you or your representative must immediately notify the EEO officer in writing (Designation form attached). Unless you state otherwise, in writing, all official correspondence from the Agency will be sent to your representative with copies to you. If you designate an attorney to represent you, all documents and decisions will be sent to your attorney, not to you, and the time frames for receipt of materials by you will be computed from the time of receipt by your representative.

    Upon receipt of this Notice, please date and sign the original in the space provided below and return it to me. Please retain the enclosed duplicate copy for your files.

    Attachments: Form DI-1892 (and/or Addendum B)

    Designation of Representative Form

    I have read and understood all of the above information.

    Aggrieved Person's Signature                                                                        Date:

    ___________________________________________                                 _______________________________

     

    NOFI and Right to File Complaint Form: December 1998

    Notice of Final Interview/Right to File a Complaint

    EEO Counselor's Record of Issuance

    This notice was delivered on the date indicated to the Aggrieved named above by the following method:

  •    Hand Delivered


    Date Delivered _________

 

  • Certified/ Registered Mail

    Certified Mail#: ________ 

    Date Mailed: _________




    _______________________________

    Counselor's Signature & Date

1 If filing under 373 DM Chapter 7, this sentence does not apply.