Fillable Office of Congressional Workplace Rights Claim Form (Office of Congressional Workplace Rights)

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Office of Congressional Workplace Rights Claim Form (Office of Congressional Workplace Rights)

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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 402(a)(2) 08/2019
Office of Congressional Workplace Rights
Claim Form
Instructions
All claims alleging violation(s) of section(s) 102(c) or 201-207 of the Congressional Accountability Act of 1995 (CAA),
as amended by the Congressional Accountability Act of 1995 Reform Act, are initiated by filing this Claim Form with
the Office of Congressional Workplace Rights (OCWR).
You have the right to receive assistance from an OCWR Confidential Advisor.
IMPORTANT: If you have questions or concerns about how to complete this Claim Form, the CAA process, or
the specific employment laws applicable to your workplace, and you do not have a designated attorney
representative, you have the right to consult, at no cost to you, with an OCWR Confidential Advisor. The
Confidential Advisor can inform you about your rights under the CAA and the OCWR’s procedures, discuss
your concerns, and consult with you concerning your claims and the options that are available to you under
the CAA for resolving them. The Confidential Advisor will provide these services 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.
Filing and Submission:
This Form must be filed with the OCWR prior to the expiration of the 180-day period, which begins on the date of
the alleged violation of the CAA. The OCWR will not accept a Claim Form after the applicable deadline. Filing this Form
initiates formal proceedings on your claim(s) alleging that the CAA has been violated. Please be advised that
immediately after you submit your Claim Form, a copy will be provided to your employing office.
All 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 Claim Form (continued) Page 2 of 7
Office of Congressional Workplace Rights
OCWR Form 402(a)(2) 08/2019
Claim Requirements:
It is important that you complete this Claim Form thoroughly, providing all required information and describing the facts
and circumstances that you believe violated your rights under the CAA. A claim filed with the OCWR must contain the
following:
Section A:
o 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 The specific section(s) of the CAA that you believe the employing office violated in its action(s) or
conduct toward you.
Section C:
o Your specific allegation(s), including what happened, who was involved, and all relevant date(s) of
the incident(s), and your explanation why the challenged conduct violates the section(s) of the CAA
that you specified.
Section D:
o A brief statement of the remedy(ies)/outcome(s) you are seeking by filing this 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 filing a 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.
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.
OCWR Claim Form (continued) Page 3 of 7
Office of Congressional Workplace Rights
OCWR Form 402(a)(2) 08/2019
Section A:
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):
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 B 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 B below.)
Yes ______ No ______ Name of Member: ________________________________________
OCWR Claim Form (continued) Page 4 of 7
Office of Congressional Workplace Rights
OCWR Form 402(a)(2) 08/2019
Section B: I allege that by engaging in the conduct described in Section C below, the employing office violated the
following section(s) of the CAA. (Check all that apply. For any alleged violation under section 201, please fill in the
relevant information – for example, “Sex: Female”; “Age: 53”; etc.)
For more information about any of these laws, please contact our office at (202) 724-9250 or visit our website at
www.ocwr.gov.
o Section 201 – Discrimination
o Race:______________________________________
o
Color:_____________________________
o Sex:_______________________________________
o
Religion:___________________________
o National Origin:______________________________
o
Age (40 or over) ____________________
o Disability:___________________________________
o
Genetic Information: _________________
o Section 201 – Harassment
o Race:______________________________________
o
Color:_____________________________
o Sex:_______________________________________
o
Religion:___________________________
o National Origin:______________________________
o
Age (40 or over) ____________________
o Disability:___________________________________
o
Genetic Information: _________________
o Section 202 – Family & Medical Leave
o Family Medical Leave Act (Denial or Interference)
o
Family Medical Leave Act (Retaliation)
o Section 203 – Fair Labor Standards
o Minimum Wage o Overtime Pay
o
Equal Pay
o
Child Labor o Lactation
o Section 204 – Employee Polygraph Protection
o Section 205 – Worker Adjustment & Retraining Notification
o Section 206 – Uniformed Services Employment & Reemployment Rights
o Army o Marines
o
Navy
o
Air Force
o Reserves o National Guard
o
Other:_________________________________
Discrimination_________ Harassment__________ Reemployment Rights____________
o Section 206(A) – Veterans Employment Opportunities
o Army o Marines
o
Navy
o
Air Force
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.
(continued on the next page)
OCWR Claim Form (continued) Page 5 of 7
Office of Congressional Workplace Rights
OCWR Form 402(a)(2) 08/2019
Section C: I allege that the employing office identified in Section A above violated the CAA by engaging in the following
conduct: (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. For each selection in Section B above, please explain why you
believe that the conduct you described violated the CAA. Use additional pages if necessary.)
OCWR Claim Form (continued) Page 6 of 7
Office of Congressional Workplace Rights
OCWR Form 402(a)(2) 08/2019
Section D: I request the following remedy(ies)/outcome(s) for this/these alleged violation(s):
(continued on the next page)
OCWR Claim Form (continued) Page 7 of 7
Office of Congressional Workplace Rights
OCWR Form 402(a)(2) 08/2019
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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Completed 20 July 2020

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