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On , you made contact with an EEO (Department of the Treasury - U.S. Mint)

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BROWSE DEPARTMENT OF THE TREASURY - U.S. MINT (DC) FORMS

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EEO COUNSELING – INTAKE INFORMATION
On , you made contact with an EEO official.
Month, Day, Year
A. Counselee’'s Information
Name (Last, First, Middle Initial) Home Telephone No. Cellular No.
( ) ( )
Your Mailing Address (You must notify the Department of any changes of address while your complaint is pending, or your complaint may be dismissed)
Position Title Series Grade Duty Hours
Employment Status in Relation to this Complaint (Check One)
Applicant Probationary Career/Career conditional Retired (date of retirement) ________________________________
Former Employee _____________________
Other ________________________________________________________________
Date left United States Mint Specify
Name and Address of Facility Where You Work
Please select your department:
Information Technology
Manufacturing
Financial
Protection
Office of the Director
Sales and Marketing
Workforce
Solutions
Your Work Telephone No.
( )
Your Email Address
Your Supervisor’s Name Supervisor’s Telephone No.
( )
Supervisor’s Position Title
B. Discrimination Basis
Series Grade Duty Hours Supervisor’s Email Address
Prohibited discrimination includes actions taken based on the categories listed below.
Check and Particularize Each that Applies:
1. Race (Specify):
8. Age (Specify Date of Birth):
2. Color (Specify): 9. Pregnancy:
3. Religion (Specify):
10. Genetic Information:
4. Sex (Specify):
11. Sexual Orientation:
5. National Origin (Specify):
12. Parental Status:
6. Physical Disability (Specify):
13. Reprisal (Dates of prior EEO Activity):
7. Mental Disability (Specify):
C. Matter Causing Complaint or Issue
Appointment Overtime Retirement
Assignment of Duties Pay Sex Based Harassment
Awards Promotion/Non-selection: (Provide the following)
Change to Lower Grade
Position Title:
Sexual Harassment
Classification
Series & Grade:
Suspension
Converted to F/T CC
Date you learned of non-selection:
Termination During Probation
Duty Hours Reasonable Accommodation Time & Attendance
Evaluation-Appraisal Merit Pay Reassignment Training
Evaluation-Appraisal Non-Merit Pay Reinstatement Within Grade Increase
Exam / Test Removal /Separation Working Conditions
Harassment Reprimand
Other (Explain)
February 2014 (Page 1 of 3)
-
_______________________________________________________________________________
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___ ____________________________________________________________________________
___ ____________________________________________________________________________
___ ____________________________________________________________________________
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___ ____________________________________________________________________________
___ ____________________________________________________________________________
___ ____________________________________________________________________________
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___ ____________________________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
D. Description of Incident/Activity CLAIM(S) OF DISCRIMINATION
BRIEFLY describe the incident or action taken against you that you believe was discriminatory. Give the DATE when the
action occurred. Indicate what HARM, if any, came to you in your work situation as a result of this action.
On , 20 , the following occurred:______________________________________________
Month, Day Year
E. Resolution Sought
What are you seeking as a resolution to your complaint?
F. Comparative Employees
Explain why, based on the factors you cited in Section B, you believe that you were treated differently than other employees or
applicants in similar situations.
1.
(Name of Comparative Employee)
was treated differently than I when:
(Factor(s) describing comparative employee, i.e., Race-Black, Sex-Female)
2.
(Name of Comparative Employee)
was treated differently than I when:
(Factor(s) describing comparative employee, i.e., Race-Black, Sex-Female)
G. Official(s) Responsible for Action(s)
List the name(s) of the official(s) who took the action which prompted you to seek counseling at this time.
1a. Agency Officials Name 1b. Title, Series and Grade
2a. Agency Officials Name 2b. Title, Series and Grade
3a. Agency Officials Name 3b. Title, Series and Grade
February 2014 (Page 2 of 3)
Yes
(Date)
Yes No
Yes
(Date)
No
(Date)
(Current Status)
H. Grievance/MSPB Appeal
On the incident that prompted you to seek EEO counseling, have you:
1. Filed a grievance under the negotiated grievance procedure?
Are you a bargaining unit employee?
No If yes, ______________
(Current Status)
3. Filed a grievance under the Agency grievance system?
4. Filed an appeal with the Merit Systems Protection Board? Yes
No If yes, ______________
If yes, ______________
(Current Status)
I. Anonymity
You have the right to remain anonymous during the counseling process.
Do you desire anonymity? Yes No
J. Representation
You have the right to retain representation of your choice. (Check One)
I waive the right to representation at this time. OR I authorize the person listed below to represent me.
Name of Representative
Organization
Telephone No.
Email Address
Mailing Address (Street or P.O. Box, City, State and Zip +4)
K. Documentation
Please attach any documentation you wish to submit to support your allegation(s). Include a copy
of any written action(s) that caused you to seek counseling at this time.
Note: If you are alleging mental and/or physical disability, it is important for you to submit medical documentation of your disability during the counseling process.
L. Privacy Act Notice
Privacy Act Notice. The collection of this information is authorized by The Equal Employment Opportunity Act of 1972; 42 U.S.C.2000e-16;
PL 95-602 as amended; 5USC 1303 and 1304; 5 CFR 5.2 and 5.3; 29 CFR 1614.105; the Age Discrimination in Employment Act of 1967, as
amended 29 U.S.C. 633a; the Rehabilitation Act of 1973, as amended, 29 U.S.C. 794a; and Executive Order 11478, as amended. The information
supplied will be used to resolve the EEO counseling matter(s) you have raised during counseling. This information may be discussed with
designated officers and employees of the Department in order to resolve the matters you have raised.
M. Authorization
Please Print Your Name Here
Your Signature Date Signed
Feb
ruary 2014
(Page 3 of 3)
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Completed 26 January 2021

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