Fillable FEDERAL SERVICE IMPASSES PANEL REQUEST FOR ASSISTANCE OMB (FLRA)

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FEDERAL SERVICE IMPASSES PANEL REQUEST FOR ASSISTANCE OMB (FLRA)

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The FEDERAL SERVICE IMPASSES PANEL REQUEST FOR ASSISTANCE OMB (FLRA) form is 2 pages long and contains:

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  • 3 check-boxes
  • 27 other fields

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File type: PDF

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FEDERAL SERVICE IMPASSES PANEL
REQUEST FOR ASSISTANCE
INSTRUCTION: File an original and one copy of this
request (including attachments) with the Executive
Director, Federal Service Impasses Panel, 1400 K Street,
NW, Washington, DC 20424-0001. Also serve a copy of
the request (with attachments) on the other party to the
dispute and on the mediator, and submit a written
statement of such service to the Executive Director.
Telephone number (202) 218-7790; Fax Number (202)
482-6674.
Form Approved:
OMB No. 3070-0007
Date:
1. This is a request to the Panel, filed under title 5 of U.S. Code and the Panel’s regulations to:
(Check One)
(a) □ Consider a negotiation impasse.
(b) □ Approve a joint request for a binding arbitration procedure to resolve a negotiation impasse.
(c) □ Consider an impasse resulting from an agency determination not to establish or terminate a
compressed work schedule under the Federal Employees Flexible and Compressed Work
Schedules Act.
2. (a) Name of Agency
(b) Address
(c) Person to Contact
Title
(d) Phone No.
(e) Fax No.
3. (a) Name of Labor Organization
(b) Address
(c) Person to Contact
Title
(d) Phone No.
(e) Fax No.
4. Description of Bargaining Unit
5. Number of Employees in Bargaining Unit
Date Labor Agreement Expires
6. (a) If term 1(a) is checked, attach information containing (1) the issues at impasse and requesting
party’s summary position thereon; (2) the number, length, and dates of negotiation and mediation
sessions held; (3) the name and address of the mediator; and (4) the FMCS case number, if
known.
Jul
Aug
1
2
2009
2010
(b) If item 1(b) is checked, attach information containing (1) the issues at impasse; (2) the number,
length, and dates of negotiation and mediation sessions held; (3) the name and address of the
mediator; (4) the FMCS case number; (5) the issues to be submitted to the arbitrator; (6) a
statement as to whether any of the proposals to be submitted to the arbitrator contain questions
concerning the duty to bargain and a statement of each party’s position concerning such
questions; and (7) the arbitration procedures to be used.
(c) If item 1(c) is checked, attach information containing (1) the number, length, and dates of
negotiation sessions held; (2) the schedule or proposed schedule which is the subject of the
agency’s determination; (3) the agency’s written determination and the finding on which the
determination is based, including, in a case where the finding is made by a duly authorized
delegatee, evidence of a specific delegation of authority to make such a finding; (4) a copy of any
collective bargaining agreement between the parties and any other agreements concerning
alternative work schedules; and (5) a summary of the position of the initiating party with a
respect to the agency’s determination.
7. (a) Name of Individual Filing this Request
Title
(b) Address
(c) Signature
(d) Phone No.
(e) Fax No.
8. If this is a joint labor-management request.
(a) Name of Other Individual Filing This Request
Title
(b) Address
(c) Signature
(d) Phone No.
(e) Fax No.
FLRA Form 14
Public reporting burden for this collection of information is estimated to average ½ hours per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining data
needed and completing and reviewing the collection of information. Send comments regarding this burden
estimate or any other aspect of this collection of information including sessions for reducing the burden to
Federal Service Impasses Panel, 1400 K Street, NW, Washington, DC 20424-0001; and to the Office of
Information and Regulatory Affairs, Office of Management and Budget, Washington, DC 20523. This form
is not valid unless an OMB control number is displayed on the form.
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FEDERAL SERVICE IMPASSES PANEL REQUEST FOR ASSISTANCE OMB (FLRA)

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Completed 26 January 2021

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