Fill - Free fillable Office of Congressional Workplace Rights Amended Claim Form (Office of Congressional Workplace Rights) PDF form

Office of Congressional Workplace Rights

110 Second Street, SE, Room LA-200 | Washington, DC 20540-1999

(202) 724-9250 (O) | (202) 426-1913 (F)

OCWRefile@ocwr.gov | https://socrates.ocwr.gov

www.ocwr.gov

OCWR Form 4.08(d) 08/2019

Office of Congressional Workplace Rights

Amended Claim Form

Instructions

A claimant may file one Amended Claim Form as a matter of right, within fifteen (15) days after filing of the initial

(original) Claim Form, pursuant to section 4.08(d) of the Office of Congressional Workplace Rights (OCWR) Procedural

Rules.

IMPORTANT: If you have questions or concerns about how to complete this Amended Claim Form, and do

not have a designated attorney representative, you have the right to receive assistance from an OCWR

Confidential Advisor. The Confidential Advisor will provide these services, at no cost to you, on a privileged

and confidential basis. The Confidential Advisor may not, however, act as your representative in any

proceeding under the Congressional Accountability Act of 1995 (CAA), as amended by the Congressional

Accountability Act of 1995 Reform Act. If you would like to request the assistance of the Confidential Advisor,

please contact the OCWR at (202) 724-9250 or send an email at ConfidentialAdvisor@ocwr.gov.

OCWR assigned you a Case Number after you filed your initial Claim Form. That Case Number must be

provided on this Amended Claim Form. If no Case Number has been assigned to you, please contact the OCWR

at (202) 724-9250 or send an email at OCWRefile@ocwr.gov.

Filing and Submission:

This Form must be filed with the OCWR NO LATER THAN 15 calendar days after the date you filed your initial

Claim Form. The OCWR will not accept an Amended Claim Form after the applicable deadline. Please be advised

that immediately after you submit your Amended Claim Form, a copy will be provided to your employing

office.

All Amended Claim Forms either must be e-filed (https://socrates.ocwr.gov), emailed (OCWRefile@ocwr.gov), faxed

(202-426-1913), or hand-delivered to: Office of Congressional Workplace Rights, John Adams Building,

110 Second Street, SE, Room LA-200, Washington, DC 20540-1999.

OCWR Amended Claim Form (continued) Page 2 of 7

Office of Congressional Workplace Rights

OCWR Form 4.08(d) 08/2019

Amended Claim Requirements:

It is important that you complete this Amended Claim Form thoroughly, providing all required information and describing

the facts and circumstances that you believe violated your rights under the CAA. An Amended Claim Form filed with

the OCWR must contain the following:

 Section A:

o Your case number; your contact information, including full name, job title, home address, home

phone number, cell phone number, work phone number, and at least one personal email address;

and

o The name of the employing office that committed the alleged violation(s) of your CAA rights or in

which the alleged violation(s) occurred, as well as the employing office’s address and telephone

number.

 Section B:

o Only if you wish to ENTIRELY replace your initial Claim Form, complete Section B.

o Your specific allegation(s), including what happened, who was involved, the relevant date(s) of the

incident(s), and an explanation why the challenged conduct violated the section(s) of the CAA that

you specified.

 Section C:

o The section(s) of the CAA that you are adding to your initial claim, if any.

o The section(s) of the CAA that you are eliminating from your initial claim, if any.

 Section D:

o For the specific section(s) of the CAA that you are adding to your claim in Section C part (i), your

specific allegation(s), including what happened, who was involved, the relevant date(s) of the

incident(s), and an explanation why the challenged conduct violated the section(s) of the CAA that

you specified.

 Section E:

o A brief statement of the remedy(ies)/outcome(s) you are seeking in this Amended Claim Form;

 The signed declaration included at the end of this Form.

Confidentiality:

All proceedings and deliberations of the OCWR Hearing Officers and the OCWR Board of Directors, including any

related records, are confidential, pursuant to section 416 of the CAA. Further, the OCWR shall maintain confidentiality

in the confidential advising process, mediation, and the proceedings and deliberations of the OCWR Hearing Officers

and the OCWR Board of Directors, in accordance with sections 302(d)(2)(B) and 416(a)-(b) of the CAA, except as

provided in sections 302(d) and 416(c)-(e) of the CAA. However, during the course of any proceeding under the CAA,

a covered employee is not prohibited from disclosing the factual allegations underlying the covered employee’s claim,

and an employing office is not prohibited from disclosing the factual allegations underlying the employing office’s

defense to the claim. See section 416(f) of the CAA.

For more information about amending your claim, please refer to the OCWR website at www.ocwr.gov. If you have

any additional questions, please contact the OCWR at (202) 724-9250.

If you have a disability and need assistance with completing this Form, please contact the OCWR.

OCWR Amended Claim Form (continued) Page 3 of 7

Office of Congressional Workplace Rights

OCWR Form 4.08(d) 08/2019

At any time, an employee or an employing office may seek information from the OCWR on the OCWR’s procedures

and on the protections, procedures, and rights and responsibilities available under the CAA. The OCWR will maintain

the confidentiality of requests for such information.

Section A:

CASE NUMBER: _____________________________

Name: Job Title:

Mailing Address:

Home Phone: Cell Phone:

Work Phone: Email Address 1:

Email Address 2:

Employing Office Involved in the Alleged CAA Violation:

Employing Office’s Address:

Employing Office’s Phone Number:

Date(s) of Alleged CAA Violation(s):

Name(s) & Title(s) of Individual(s) Involved in the Alleged CAA Violation(s):

OCWR Amended Claim Form (continued) Page 4 of 7

Office of Congressional Workplace Rights

OCWR Form 4.08(d) 08/2019

Are you arguing that a Member of Congress personally committed an act or acts of harassment against you in

violation of section 201 or 206 of the CAA? (See Section C below.)

Yes _____ No _____ Name of Member: ________________________________________

Are you arguing that a Member of Congress personally committed an act or acts of retaliation against you

because you made a claim of harassment in violation of section 201 or 206 of the CAA? (See Section C below.)

Yes _____ No _____ Name of Member: __________________________________________

Section B: If you wish to ENTIRELY replace your initial Claim Form, complete this Section.

Please set forth a clear statement of the conduct being challenged, including the date(s) of the conduct and the name(s)

and title(s) of the individual(s) involved. Also explain why you believe that the challenged conduct violates a section(s)

of the CAA. (Use additional pages if necessary.)

_____________________________________________________________________________________________

OCWR Amended Claim Form (continued) Page 6 of 7

Office of Congressional Workplace Rights

OCWR Form 4.08(d) 08/2019

o Reserves o National Guard

o

Other:_________________________________

o Section 207 – Reprisal

o Because you opposed a practice made unlawful by the CAA.

o Because you initiated proceedings, filed a claim, or testified, assisted, or participated in any manner in a hearing

or other proceeding under the CAA.

ii) What, if any, section(s) of the CAA are you eliminating (removing) from your initial claim?

_____________________________________________________________________________________________

Section D: For each section(s) of the CAA that you are adding to your initial claim in Section C part (i), please set

forth a clear statement of the conduct being challenged, including the date(s) of the conduct and the name(s) and

title(s) of the individual(s) involved. Also explain why you believe that the challenged conduct violates the section(s) of

the CAA that you specified. (Use additional pages if necessary.)

_____________________________________________________________________________________________

OCWR Amended Claim Form (continued) Page 7 of 7

Office of Congressional Workplace Rights

OCWR Form 4.08(d) 08/2019

_____________________________________________________________________________________________

Section E: Does this change any or all of the remedies that you stated you are seeking in your initial Claim Form?

Please explain what remedy(ies) you are now seeking.

_____________________________________________________________________________________________

Declaration

You must provide an oath or affirmation as to the truth of the assertions contained in any pleading that you file with the

Office of Congressional Workplace Rights (OCWR), pursuant to section 401(f) of the Congressional Accountability Act

of 1995, as amended by the Congressional Accountability Act of 1995 Reform Act. All submitted documents must be

signed by you personally or, if applicable, by your attorney of record. Whoever signs the document must provide their

address, e-mail address, and telephone number.

By presenting a document to the OCWR, you and/or your attorney are certifying that to the best of your knowledge,

information, and belief:

(1) it is not being presented for any improper purpose, such as to harass, cause unnecessary delay, or needlessly

increase the cost of resolving the matter;

(2) the claims, defenses, and other legal contentions you are advocating are warranted by existing law or by a

non-frivolous argument for extending, modifying, or reversing existing law or for establishing new law;

(3) the factual contentions have evidentiary support or, if specifically so identified, will likely have evidentiary

support after a reasonable opportunity for further review or discovery; and

(4) the denials of factual contentions are warranted on the evidence or, if specifically so identified, are reasonably

based on belief or a lack of information.

If, after notice and a reasonable opportunity to respond, the OCWR determines that these requirements have been

violated, the OCWR may impose an appropriate sanction for such violation.

By signing this Form, you and/or your attorney attest that you have read, understand, and will comply with the above-

stated requirements.

Claimant’s Signature

Date

*If you have a representative, you must designate that representative on a separate Notice of Designation of

Representative Form provided by the OCWR.

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