Fillable Privacy Act Statement (Department of the Treasury - U.S. Mint)

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Privacy Act Statement (Department of the Treasury - U.S. Mint)

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Privacy Act Statement
AUTHORITY: 29 U.S.C. § 206(d); 29 U.S.C. § 791; 42 U.S.C. § 2000e; 42 U.S.C. § 2000ff-(2);
29 U.S.C. § 633a; 5 U.S.C. § 1303-1304; 5 CFR § 5.2-5.3; 29 CFR § 1614.105, .107; Executive
Order 11478, as amended; and Executive Order 13152 and Management Directive 110 (August
2015).
PRINCIPAL PURPOSE(S): This information is being collected for the sole purpose to record a
pre-complaint allegation of employment discrimination with the Department of the Treasury on
the grounds of race, color, religion, sex (including pregnancy, sexual orientation and gender
identity), national origin, age, disability, protected genetic information, parental status, or
reprisal. An employee or applicant must participate in pre-complaint EEO counseling to
informally resolve the allegation(s) per § 1614.105, prior to filing a formal EEO complaint of
discrimination. Information provided on this form will be used to inform the aggrieved of his/her
rights and responsibilities in the pre-complaint/formal EEO complaint of discrimination process.
The information captured on this form will be used by the Department of the Treasury to ensure
the aggrieved has been informed of his/her rights and responsibilities in the pre-complaint/
formal EEO complaint of discrimination process.
ROUTINE USE(S): The information on this form may be disclosed as generally permitted under
5 U.S.C. §552a(b) of the Privacy Act of 1974, as amended. This includes using this information
as necessary and authorized by the routine uses published in Treasury 013--Department of the
Treasury Civil Rights Complaints and Compliance Review Files system of records notice (FR Doc
No: 2011-22977).
PAPERWORK REDUCTION ACT STATEMENT: In accordance with the Paperwork Reduction
Act of 1995, The Department of the Treasury may not conduct or sponsor, and the respondent is
not required to respond to this collection of information unless it displays a valid OMB Control
Number. The valid OMB Control Number for this information collection is 1505-0262. The
collection of this information is voluntary. However, the information is necessary to determine if
your complaint of employment discrimination is acceptable for further processing in accordance
with EEOC, 29 C.F.R. §1614. The time required to complete this information collection is
estimated to average 20 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing the
form. Send comments regarding this burden estimate or any other aspects of this collection,
including suggestions for reducing this burden, to Department of the Treasury, Office of Civil
Rights and Diversity, 1500 Pennsylvania Avenue, N.W., Washington, DC 20220.
TD F 62-03.7
Revised 2/2017
OMB No. 1505-0262
Expiration Date: 03/21/2022
Department of the Treasury
United States Mint
Name of the Aggrieved: _______________________ Pre-Complaint Number: _____________
Notice of Rights and Responsibilities
Federal Sector Equal Employment Opportunity Regulations
29 CFR Part 1614
Use of the EEO complaint process is voluntary. However, pre-complaint EEO counseling is a mandatory requirement for
filing a formal EEO discrimination complaint under the Equal Employment Opportunity Commission (EEOC) Regulations at
29 CFR Part 1614. The regulations also require that individuals seeking EEO counseling be advised, in writing,
of their rights and responsibilities. This "Notice of Rights and Responsibilities" is provided in compliance with
the regulations. If you do not pursue EEO counseling after the initial inquiry, no further action will be taken with
respect to the matters discussed. If you do receive further EEO counseling or pursue an Alternative Dispute
Resolution (ADR) procedure, and the matter is not resolved, you will be given a "Notice of the Right to File a
Formal Discrimination Complaint" form as explained below.
Anonymity
•
You have the right to remain anonymous during informal EEO counseling. However, anonymity may restrict
the
EEO
Counselor from achieving informal resolution of the claim(s) you have raised. If you choose to remain anonymous,
your name will appear on the EEO Counseling Report. Only the EEO Counselor, EEO Office or Resolution Program
Manager will have a copy of the report, unless you file a formal complaint [§1614.105(g)].
• If your informal complaint includes allegations of sexual harassment or hostile working environment, you will have no
right to anonymity. These claims must be reported immediately to the appropriate offices for a prompt investigation,
• If you file a formal EEO discrimination complaint, you will have no right to anonymity, and your filing of a formal
EEO discrimination complaint will not be confidential [§1614.105(g)].
I do not wish to remain anonymous
I wish to remain anonymous
Representation
• You have the right to be accompanied by a representative of your own choosing at every stage in the processing of
your complaint, including the EEO counseling stage, as long as there is no conflict of interest or position. The EEO
Counselor is not an advocate or representative for either party, but acts strictly as a neutral party in the EEO process
[§1614.605(a) and (c)].
If you wish to be represented, it is your responsibility to complete the "Designation of Representative" form that may be
obtained from the EEO Counselor. You must sign this form and return it to the EEO Counselor, or to the Office of Civil
Rights and Diversity if a formal EEO discrimination complaint is filed. You should read this form carefully, discuss it with
your representative, and come to a clear understanding of the terms and conditions specified on the form. If you later
wish to proceed without representation, or if you wish to change your representative, you must file a written notice with
the EEO Counselor or the Office of Civil Rights and Diversity [§1614.605(a)].
Freedom from Reprisal
• You, your representative, and your witnesses shall be free from reprisal in the presentation and processing of a
complaint, including EEO counseling, or at any time thereafter [§1614.101(b)].
Notice of Rights and Responsibilities
TD F 62-03.7
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Revised 2/2017
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Department of the Treasury
United States Mint
Election of Process
• If the agency agrees to offer Alternative Dispute Resolution (ADR) in your particular case and you agree to
voluntarily participate,
the traditional EEO counseling process will not be used
[§1614.105(b)(2)].
• If ADR is not offered or not accepted, the EEO counseling process will take place for 30 days in an attempt to resolve
y
our claims informally. You may grant an extension for EEO counseling up to an additional 60 days, at which time
you
will
receive your Notice of Right to File a Formal EEO Discrimination C
omplaint.
• If
you are covered by a collective bargaining agreement that permits claims of discrimination to be raised, you
may
elect
to proceed either under the EEOC regulations or under the negotiated procedure, but not both. The filing of
a
writ
ten complaint in either forum indicates an election. Use of the pre-complaint process does not constitute an
election
to proceed under the regulations [§1614.301].
• If
an action taken is appealable to the Merit Systems Protection Board (MSPB) and you raise the issue
of
discriminati
on during the processing of that action, you have the right to file either a “mixed case
complaint”
with the agency or a “mixed case appeal” with MSPB. You have 30 days from the date of the action to file an
appeal
with MSPB and 15 days from the date of the “Notice of Right to File a Formal EEO Discrimination Complaint”
or
30 days
after the initial interview to file a formal EEO discrimination complaint with the agency. If you file a mixed cas
e
complaint,
your appeal rights will be to MSPB (not EEOC). You may not file both a mixed case appeal with MSPB
and
a mixed
case complaint on the same matter. The process selected first is deemed the elected process
[§1614.302].
Filing a Formal Complaint
• Prior to or at the end of the 30-day EEO counseling period, unless you agree to a 60-day extension and do not engage
in ADR, a
final interview will be conducted and you will be given a "Notice of Right to File a Formal EEO Discrimination
Complaint”. If an extension is granted or you engage in ADR, you will be given a Notice of Right to File a Formal EEO
Discrimination Complaint not later than 90 days from the date EEO counseling was first sought
[§1614.105(d)].
• The
Notice of Right to File a Formal Discrimination Complaint shall inform you
of:
• the
right to file a formal individual or class complaint within fifteen (15) calendar days of receipt of the N
otice;
• the appropriate official with whom the complaint should be filed;
and
• your duty to immediately inform the agency if you obtain representation.
• The
EEO formal discrimination complaint must be in writing and signed by you, or your designated representative,
if
s/
he is an attorney. Your complaint must be precise and describe the actions or practices which form the basis
of
the c
omplaint. The Notice of Right to File provides you with the link/web address for the complaint form and instruc
tions
for
filing a formal EEO discrimination complaint, along with information where and with whom the formal c
omplaint must
be filed [§1614.106].
• Only
issues or claims raised at the EEO counseling stage, or claims that are like or related to those that were
raised,
may
be the subject of a formal complaint, or an amendment to a complaint [§1614.105(b)(1) and §
1614.106(d)].
No
tice of Rights and Responsibilities
TD F 62-03.7
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Department of the Treasury
United States Mint
•
If you have filed two or more EEO complaints, the agency must consolidate them after appropriate notice. When a
complaint has been consolidated with one or more earlier complaints, the agency shall complete its investigation within
the earlier of 180 days after the filing of the last complaint or 360 days from the filing of the first complaint. You may
request a hearing before an EEOC Administrative Judge at any time after 180 days from the filing of your EEO
complaint [§1614.606].
Processing of Formal Complaints
• After you have filed a formal EEO discrimination complaint, you will receive notification from the Office of Civil Rights
and Diversity regarding the receipt and acceptance of your complaint. If your complaint is accepted, an investigation will
be conducted. If your complaint is not accepted, you will be given appropriate appeal rights.
• After the investigation is conducted, you and your representative will be provided a copy of the investigative file, and
notified of your right to request a hearing (in a non-mixed complaint) before an EEOC Administrative Judge or an
immediate final agency decision by the agency:
• The investigation shall be completed within 180 days from the date of filing the formal complaint;
• If the complaint was amended, the investigation shall be completed within the earlier of 180 days after the last
amendment or 360 days after the filing of the original EEO complaint;
• Upon mutual written agreement, the parties may voluntarily agree to an extension of the investigation for a period
of not more than an additional 90 days [§1614.108(f)].
• You may request a hearing before an EEOC Administrative Judge (in a non-mixed case) at any time after 180 days of
the filing of the formal EEO discrimination complaint, or within 30 days of receipt of the investigative file, whichever
comes first. If your complaint has been consolidated, you may request a hearing 180 days after the filing of the first
complaint. If you elect an EEOC hearing, your request should be made, in writing, directly to the appropriate EEOC
office. You must notify the Office of Civil Rights and Diversity of your hearing request [§1614.108(f)].
• If you do not elect a hearing, you have the right to request a final agency decision on the record from the agency after
completion of the investigation and within 30 days from receipt of the investigative file [§1614.110].
Sexual Harassment
•
If you raise a claim of sexual harassment, you have the right to bring that issue to the attention of the bureau head and
the appropriate Inspector General.
Parental Status
•
If you raise a claim of parental status, these non-statutory claims are processed through an administrative procedure,
where you will receive a final agency decision. However, there is no right to a hearing by, or an appeal to, the Equal
Employment Opportunity Commission.
Notice of Rights and Responsibilities
TD F 62-03.7
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Revised 2/2017
Page 3 of 5
Department of the Treasury
United States Mint
Other Rights and Responsibilities
•
You are entitled to a reasonable amount of official time to prepare your EEO complaint and respond to agency or EEOC
requests for information. If your representative is an agency employee, the representative shall also be entitled to a
reasonable amount of official time [§1614.605(b)].
• You have a duty to mitigate damages, e.g., interim earning or amounts that could be earned by the individual
with reasonable diligence generally must be deducted from an award of back pay [§1614.105(b)(1)].
• You are required to keep the agency and EEOC informed of your current mailing address [§1614.105(b)(1)].
• You are required to serve copies of hearing requests and appeal papers on the agency [§1614.105(b)(1)].
Class Complaints
•
If you wish to file a class complaint, the procedures for filing and the responsibilities of a class agent will be explained
to you by the counselor [§1614.105(b)(1)].
Right to File a Civil Action in Non-Mixed Cases
• You may file a civil action in an appropriate United States District Court:
(a) After 180 days from the effective date of filing the formal EEO discrimination complaint, if a final decision has not
been issued, and appeal has not been filed;
(b) Within 90 days of receipt of the EEOC's final decision on an appeal; or
(c) After 180 days from the date of filing an appeal with the EEOC, if there has been no final decision by the EEOC
[1614.407].
Right to File Civil Action in Mixed Cases
• If your formal EEO discrimination complaint concerns a matter appealable to the Merit Systems Protection Board (MSPB)
(a "mixed case"), you may file a civil action in United States District Court:
(a) Within 30 days of receipt of a final decision by the agency unless an appeal is filed with MSPB;
(b) Within 30 days of receipt of notice of the final decision or action taken by the MSPB if you do not file a petition for
consideration with the EEOC;
(c) Within 30 days of receipt of notice that the EEOC concurs with or has determined not to consider the decision of the
MSPB;
(d) If the EEOC issues a decision different from the decision of the MSPB, within 30 days of receipt of notice that the
MSPB concurs in and adopts the decision of the EEOC;
(e) If the MSPB does not concur in the decision of the EEOC, reaffirms its initial decision, or reaffirms its initial decision
with a revision, within 30 days of receipt of notice of the decision of the Special Panel;
Notice of Rights and Responsibilities
TD F 62-03.7
Initials
__________
Revised 2/2017
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Department of the Treasury
United States Mint
(f) After 120 days from the date of the filing of the formal complaint if there is no final agency action or appeal to
the MSPB;
(g) After 120 days from the date of filing an appeal with MSPB, if the MSPB has not made a decision; or
(h) After 180 days from the date of filing a petition for consideration with EEOC, if there is no decision by the
EEOC, reconsideration decision by the MSPB, or decision by the Special Panel [§1614.310].
Right to File a Civil Action Under the Age Discrimination in Employment Act (ADEA)
•
If you believe that you have been subjected to prohibited age discrimination, as an alternative to filing a complaint
under the EEOC regulations, you may file a civil action in an appropriate U.S. District Court at any time within 180 days
of the unlawful discriminatory incident, act, event, decision or personnel action, provided that you give the EEOC notice
of intent to sue at least 30 days in advance of filing suit [§1614.201(a)].
Right to File a Civil Action under the Equal Pay Act
•
If you believe you have been subjected to prohibited sex-based wage discrimination, you may file a civil action in an
appropriate U.S. District Court under the Equal Pay Act simultaneously with claims raised under Title Vll and processed
under 29 CFR Part [§1614.408].
Right to a Court Appointed Attorney
•
If you elect to file a civil action, under Title Vll or the Rehabilitation Act, and you do not have or cannot afford the
services of an attorney, you may request that the Court appoint an attorney to represent you and that the Court permit
you to file the action without payment of fees, costs, or security.
Use of Complaint Form
•
You may use the individual complaint form to file your complaint of discrimination. Use of the form is not required, but
is recommended. However, if you do not submit the complaint form, you must provide sufficient information to
demonstrate that your complaint is acceptable under applicable laws and regulations governing complaint processing
in Federal agencies [§1614.106(c)].
I have been advised of my rights and responsibilities and have received a copy of this Notice on this
date.
__________________
____________________________________________
Signature of Aggrieved/Representative
Dat
e
Notice of Rights and Responsibilities
TD F 62-03.7
Initials __________
Revised 2/2017
Page 5 of 5
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Completed 26 January 2021

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