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 by the aggrieved to voluntarily participate in
mediation under the EEO Alternative Dispute Resolution (ADR) process, which automatically
extends the process an additional 60 calendar days, not to exceed a total of 90 days. The
information captured on this form will be used by the Department of the Treasury to record the
decision of the aggrieved to extend counseling to participate in the ADR 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 5 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 62-03.4
Revised 2/2017
