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Court Services and Offender Supervision Agency for the (Court Services and Offender Supervision)

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Court Services and Offender Supervision Agency
for the District of Columbia
Office of the Director
Equal Employment Opportunity
Diversity and Special Programs
CSOSA EEO Form 200 (April 2010)
COMPLAINT OF DISCRIMINATION
B
ASED ON RACE, COLOR, RELIGION, SEX
NATIONAL ORIGIN, AGE, DISABILITY, AND/OR REPRISAL
Privacy Act Information:
The information on this form is collected pursuant to 29 CFR, Part 1614, and is given voluntarily. The information
is used primarily in the processing of Equal Employment Opportunity complaints. Failure to provide the
information may delay or prevent the processing of the complaint. The information may be disclosed to appropriate
Federal, State, or local agencies when relevant to civil, or regulatory investigations or prosecutions; in judicial or
administrative proceedings; and to authorized officials involved in investigation or settlement of EEO grievances,
complaints and appeals. The form must be signed and dated by the complainant to verify the accuracy of the
information.
1. Complainant’s full name (Last, First, Middle):
2. Birth Date
3. Work telephone number (Include Area Code):
4. Home telephone or Cell No. (Include Area Code):
5. Home Address (Number, Street, City, State, Zip Code):
6. Name and Address of the CSOSA/PSA office and
individual you believe discriminated against you:
7. Date (Month, Day, Year) when the most recent
alleged discrimination took place:
8. Are you now working for the Federal Government? YES NO, If “YES”, Provide the title and grade of
the job you held when the alleged discrimination took place, and the name and address of the agency where you
currently work (Include Street Number, City, State, and Zip Code):
9. Check (x) the basis(es) of alleged discrimination:
Race: Black White Amer. Indian/Alaska Native Native Hawaiian or other Pacific Islander
Asian Two or more races Other (Specify): ___________________________________
Color: Black White Other (Specify): ______________________________________________
Sex: Male Female
National Origin: Hispanic Other (Specify): ______________________________________________
Age: (Must be at least 40 years old at time of alleged discrimination) (Specify DOB)______________________
Disability: Physical Mental (Specify disability):
Reprisal/Retaliation (For previously filing an EEO complaint or otherwise engaging in EEO activity)
Religion (Specify): _________________________________________________________________
Other (Specify):
CSOSA EEO Form 200 (April 2010)
10. Have you appealed this matter to the Merit Systems
Protection Board (MSPB)? If “YES,” provide date:
YES NO Date:
_____________________________________________
11. Have you filed a grievance on this matter? If “YES,”
provide date:
YES NO Date:
____________________________________________
12. Explain why you believe you were subject to discrimination because of your race, color, religion, sex, national
origin, age, disability and/or reprisal.
13. What remedy or corrective action(s) are you seeking?
14. Did you participate in ADR during the informal complaint process?
15. Would you be willing to resolve your complaint through the ADR process?
16. Name of EEO Counselor, which you contacted concerning this alleged
discrimination.
17. Date of contact (Month, Day, Year):
18. Complainant’s Signature:
19. Date signed (Month, Day, Year):
Formal Complaint may be filed by U.S. Mail, Federal Express, Hand Delivery, or via e-mail (scanned copy) to:
Director, Office of Equal Employment Opportunity,
Diversity and Special Programs
655 – 15
th
Street, NW, Room 840
Washington, DC 20005
No faxed transmittals will be accepted.
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Court Services and Offender Supervision Agency for the (Court Services and Offender Supervision)

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Completed 18 July 2020

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