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Complaint Form DI-1892 Addendum



1. Complainant's Name: ______________________________ Place of Employment: ________________________________
Street Address:
_______________________________
Address:
________________________________
City, State, Zip Code: _______________________________ City, State, Zip Code: _________________________________
Home Phone:
______________________________
Work Phone:
_________________________________

2. DOI Office which you believe discriminated against you?
Bureau:
_________________________________
Division/Office: _________________________________
Address:
________________________________
Region
_________________________________
City/State:
________________________________
 
3. Basis(es) for believing you were discriminated against? (Check one or more, and provide the specific information)
_______ Race _________________________ _______ Age (Date of Birth) __________________
_______ Color _________________________ _______ Physical Handicap __________________
_______ Region _________________________ _______ Mental Handicap __________________
_______ Sex _________________________ _______ Sexual Orientation _________________

_______ Reprisal __________________

_______ National Origin _______________ (Date of previous EEO activity)________________
4. Allegation(s) of discrimination? (For each allegation, state the date and the specific incident causing you to believe that you have been discriminated against. FOR EXAMPLE: I was discriminated against on January 1, 1992, when I was not selected for the position of Analyst. (Use additional pages as necessary.)
5. Have you discussed your complaint with an EEO Counselor? Yes _______ No _______ (If yes, name of Counselor):
________ Date you first contacted the Counselor:___________________________
6. Are you agreeable to using the Alternative Dispute Resolution (ADR) process? Yes _______ No _______
7. Have you presented these allegations to any other forum? If so, please indicate:

_______Negotiated Grievance Procedure ______ Merit Systems Protection Board ______ Court (Civil Action) ______Other Forum

8. List the remedies which you believe will resolve your complaint: (Use additional pages, as necessary.)
9. Complainant's Signature: Date:
10. For Agency Use:

Complaint Docket Number: Date Received of Postmarked:


READ CAREFULLY! The DI-1892 B Form should only be used in cases involving sexual orientation basis or sexual orientation complaints.


You may use this form to file a complaint. This form should be used if you, as an applicant for Department of the Interior (DOI) employment or as a DOI employee, believe you have been discriminated against because of race, color, religion, sex, national origin, age, handicap, reprisal or sexual orientation by the DOI. When filing a complaint, you should provide a statement of what occurred, when the incident(s) occurred, and why you believe you were treated in a discriminatory manner. Your complaint must bear an original signature.

COMPLAINTS PROCESSING INFORMATION

  • Prior to filing a complaint, you must present the matter(s) that you believe are discriminatory to an EEO Counselor for informal resolution, within 45 calendar days from the date the incident occurred, or 45 calendar days from the effective date of a personnel action. The EEO Counselor has 30 calendar days to attempt a resolution of the matter, and conduct a final interview with you. The EEO Counselor will notify you in writing of your right to file a complaint. You have 15 calendar days to file your complaint after receipt of the Notice of Final Interview. The 15-day filing period may be waived if you show that you were not notified of the time limits for filing, or that you were prevented from meeting the time limits by circumstances beyond your control. Failure to file your complaint within the 15-calendar day period may result in the dismissal of your complaint.

  • Your written complaint should be filed by you or your designated representative with the Bureau Equal Opportunity Officer where the alleged discriminatory incident occurred, the Secretary of the Interior, the Assistant Secretary, Policy, Management and Budget, Deputy Assistant Secretary, Workforce Diversity, and or with the Director, Office for Equal Opportunity, U. S. Department of the Interior, 1849 C Street, N. W., MS-5221, Washington, D. C. 20240. If you choose to have a representative, you must designate the representative provide in writing, providing their full name and address. To expedite processing, the complaint should be filed with the EO Officer of the Bureau where the alleged discrimination arose.

  • A complaint must be in writing and must be filed within 15 days of receipt of the notice of right to file/notice of final interview a complaint required by 373 DM 7.6D or E.

  • If your complaint is accepted for processing, the investigation should be completed within 180 calendar days from the filing date of your complaint. By written agreement, you and the agency may voluntarily extend the time period for no more than an additional 90 calendar days. The DOI will provide you with a copy of the Report of Investigation (ROI). Should the DOI fail to issue the ROI within 180 days of the filing date of your complaint, you may request a hearing.

  • If you choose a hearing, the EO Officer shall forward a copy of the completed investigative record to Office of Hearing and Appeals (OHA) and request that the Director, OHA, appoint a hearing examiner to conduct a hearing. The hearing process shall be completed within 180 days from receipt of the request, unless extended. Where the hearing examiner determines that the complainant is raising or intends to pursue issues like or related to those raised in the complaint, which the Bureau has not had an opportunity to address, the hearing examiner shall remand any such issue for counseling in accordance with 373 DM 7.6, or for such other processing as ordered by the hearing examiner. Any issues raised at the hearing alleging discrimination on the basis of race, color, national origin, sex, age, religion, or disability must be referred to the EO Officer for proper processing without the hearing examiner deciding the issues.

  • The hearing examiner shall issue recommended findings of fact and conclusions of law on the merits of the complaint. The hearing examiner shall send the record of hearing including the transcript and the recommended findings and conclusions to the parties and the Director, OEO, by certified mail, return receipt requested, or other appropriate means. Within 60 days of receipt of the recommended findings and conclusions, the Director, OEO, will issue a final agency decision in accordance with 373 DM 7.11. If you are dissatisfied with the agency's decision you may, within 30 days of receipt of the decision, request reconsideration of the decision by the Assistant Secretary, PMB. The Assistant Secretary, PMB, will, within 45 days of receipt of the request, affirm or modify the decision of the Director, OEO. The decision of the Assistant Secretary, PMB, shall then be the final agency decision of the Department.

  • There are special provisions in the regulations with respect to related processes, such as mixed case complaints, negotiated grievance procedures, class complaints, etc. For further information you may wish to consult Title 29 of the Code of Federal Regulations (CFR), Part 1614 or your Bureau's EO Officer.

PRIVACY ACT STATEMENT


THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974.

AUTHORITY: 42 USC 2000E-16

PRINCIPAL PURPOSE: To establish the case records and to assist in the processing of the complaint.

ROUTINE USE: Used by EEO officials, Administrative Judges, investigators, and/or representatives of the EEOC and the Department of Justice in relation to the processing of complaints and appeals.

DISCLOSURE IF VOLUNTARY: Failure to furnish the information requested on the form may delay or impair the processing of the complaint.