INFORMATION CONCERNING THE PROCESSING OF YOUR COMPLAINT
This form should be used if you, as an employee or applicant for employment with the U.S. Department of State, believe that you have
been discriminated against because of your race, color, national origin, sex (including pregnancy and gender identity), religion, age,
physical or mental disability, protected genetic information, sexual orientation, or reprisal for prior EEO activity or reprisal for prior EEO
activity or opposition to illegal discrimination.
Your written complaint must be filed within 15 CALENDAR DAYS of the date you received a "Notice of Right to File a Complaint."
Failure to submit a timely complaint can result in the dismissal of your formal complaint in accordance with 29 C.F.R. § 1614.107.
Your EEO Counselor is not authorized to receive your formal complaint on behalf of the Office of Civil Rights (S/OCR). Your
complaint must be submitted directly to S/OCR by email, fax or mail at the contact information provided below.
DS-3079
10-2015
Instruction Page 1 of 1
READ INSTRUCTIONS CAREFULLY
Email:
Fax:
Telephone:
Mailing Address:
SOCRComplaintChannel@state.gov
(202) 647-4969
(202) 647-9295
U.S. Department of State
2201 C Street, NW, Room 7428
Washington, DC 20520-7428
Submitting your complaint by email is the recommended method to ensure prompt processing of your formal complaint. If
filing by mail, please allow at least 15 calendar days for receipt.
Please be specific in stating the facts concerning your complaint when completing this form. Keep in mind that you may agree to
resolve your complaint at any stage in the process. Also, you may have a representative at all stages of the processing of your
complaint.
If your complaint is dismissed, you will be advised in writing of the reason(s) and informed of your right to appeal to the Equal
Employment Opportunity Commission (EEOC).
If your complaint is accepted, you will have an opportunity to talk with an investigator and to give him/her all the testimonial and
documentary evidence that you believe will support your complaint. Upon completion of the investigation of your complaint, you will
receive a copy of the investigative file. At that time you may request either: (1) an immediate final decision from the Department of
State based on the evidence in the file, or (2) a hearing and decision from an EEOC Administrative Judge.
The Director for Civil Rights issues a Final Agency Decision based on the file or a Final Order based on a decision from the EEOC. If
you are not satisfied with the agency's decision or Final Order, you will have the right to file an appeal with the EEOC's Office of
Federal Operations:
Fax:
Mailing Address:
(202) 663-7022
EEOC Office of Federal Operations
P.O. Box 77960
Washington, DC 20013
To be timely, you must file your appeal within 30 calendar days of your receipt of the Final Agency Decision or Final
Order.
For questions concerning the discrimination complaint process or completion of this form, contact S/OCR by using the contact
information listed above.
1. Name (Last, First, MI.)
FORMAL COMPLAINT OF DISCRIMINATION
U.S. Department of State
Office of Civil Rights (S/OCR)
6. Work Telephone (Include area code or country code if overseas)
3. Home Telephone (Include area code or country code if overseas)
12. Current Employer
10. Aggrieved is a(n):
Employee
Applicant
LE Staff
*Contractor - You must provide a copy of your hiring contract at the same time you file this
complaint
Other (Specify)
11. Title and Grade of Current Position
DS-3079
10-2015
PRIVACY ACT STATEMENT (5 U.S.C. § 552(a))
AUTHORITY Public Law 92-261
PRINCIPAL PURPOSE
Used for processing complaints of discrimination because of race, color, national origin, sex (including pregnancy and
gender identity), religion, age, physical or mental disability, genetic information, sexual orientation, or reprisal for prior EEO
activity or opposition to illegal discrimination. Complaints can be submitted by Department of State employees, former
employees, applicants for employment, and some contract employees.
ROUTINE USES Information will be used (a) as a data source for complaint information for production of summary descriptive statistics and
analytical studies of complaints processing and resolution efforts; (b) to respond to general requests for information under
the Freedom of Information Act; (c) to respond to requests from legitimate outside individuals or agencies (White House,
Congress, Equal Employment Opportunity Commission) regarding the status of a complaint or appeal; or (d) to adjudicate
a complaint or appeal.
DISCLOSURE Voluntary, however, failure to complete all appropriate portions of this form may lead to a delay in processing and/or
rejection of the complaint on the basis of inadequate data to continue processing.
COMPLAINANT CONTACT/PERSONAL INFORMATION
2. U.S. Citizen
9. Are you working for the Federal government?
Yes
No
Yes No
REPRESENTATIVE/ATTORNEY INFORMATION
Page 1 of 2
5. Mailing Address (Include ZIP code, if applicable)
19. Bureau/Office/Post Where Discrimination Allegedly Took Place
8. Work Address
13. Do you have a representative?
NoYes
14. If yes, provide name of representative.
15. Is your representative an attorney?
Yes No
16. Address
17. Telephone 18. E-Mail(Include area code)
20. Date(s) Alleged Discrimination Occurred
(mm-dd-yyyy) (mm-dd-yyyy) (mm-dd-yyyy) (mm-dd-yyyy) (mm-dd-yyyy)
COMPLAINT INFORMATION
4. Home E-Mail Address
7. Work E-Mail Address
27. Have you filed a grievance on the matter(s)?
Grievance Date Filed (mm-dd-yyyy)
YesNo
23. Name of EEO Counselor 24. Date Notice of Right to File Received (mm-dd-yyyy)
22. Did you discuss your complaint with an EEO Counselor?
Yes No
25. Explain specifically how you were discriminated against (treated differently from other employees or applicants) because of your race, color,
national origin, sex, religion, age, physical or mental disability, protected genetic information, sexual orientation, or reprisal for prior EEO activity or
opposition to illegal discrimination.
(Space will expand to fit. Attach additional sheets if necessary. To print the additional pages (addendum), check the print addendum box in the right
hand corner of the print dialog box.)
26. What remedies and relief are you seeking?
(Space will expand to fit. Attach additional sheets if necessary. To print the additional pages (addendum), check the print addendum box in the right
hand corner of the print dialog box.)
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29. Complainant's Signature
28. Have you filed an appeal with Merit Systems Protection Board (MSPB) on the matter(s)?
Appeal Date Filed (mm-dd-yyyy)
YesNo
Date (mm-dd-yyyy)
Race Color
Sex
Pregnancy
Sexual Orientation
Gender Identity
Religion
Age (mm-yyyy)
National OriginGenetic Information
Disability
Mental
Physical
(Check all that apply and specify)
Reprisal (Provide date. Check all that apply, and specify)
Date (mm-dd-yyyy)
Engaging in prior protected activity
Opposing discriminatory policies or practices (Specify)
(Specify)
21. Why do you believe you were discriminated against? (Check all that apply and specify.)
Other (e.g., Veteran's preference, marital status, etc.)
click to sign
signature
click to edit
dd mmm yyyy
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