EEO Counseling Intake Form

This "EEO Counseling Intake Form" is a part of the paperwork released by the U.S. Department of the Treasury - United States Mint specifically for United States residents.

The latest fillable version of the document was released on November 1, 2003 and can be downloaded through the link below or found through the department's forms library.

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EEO COUNSELING – INTAKE INFORMATION
On
, you requested an appointment with an EEO Counselor.
Month, Day, Year
Informal Intake #:
/
/
Facility Abbreviation /
FY
/ Sequential ####
A. Counselee’s Information
Name (Last, First, Middle Initial)
Home Telephone No.
Fax 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
Time in Current Position
_____Years
_____Months
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
Are you a Strategic Business Unit Employee?
Yes
No If the answer is yes, please check the following box to indicate the unit:
Chief Information’s Office
Chief Financial Office
Directors Staff
Manufacturing
Protection
Sales and Marketing
Your Work Telephone No.
Your Email Address
(
)
Your Supervisor’s Name
Supervisor’s Telephone No.
(
)
Supervisor’s Position Title
Series
Grade
Duty Hours
Supervisor’s Email Address
B. Discrimination Basis
Prohibited discrimination includes actions taken based on your Race, Color, Religion, Sex, National Origin, Age (40+), Physical and/or Mental
Disability, or in
Retaliation (for prior EEO activity).
These categories are referred to on this form as basis.
Check and Particularize Each that Applies:
1. Race (Specify):
9. Age (Specify Date of Birth):
2. Color (Specify):
10. Physical Disability (Specify):
3. Religion (Specify):
11. Mental Disability (Specify):
4. Sex (Specify):
12. Reprisal (Dates of prior EEO Activity):
5. Genetic Information
6. Sexual Orientation
7. Parental Status
8. National Origin (Specify):
C. Matter Causing Complaint or Issue
Appointment
Pay
Time & Attendance
Assignment of Duties
Promotion (Provide the following information): Position Title:
Awards
Reassignment
Series & Grade:
Change to Lower Grade
Reinstatement
Announcement Number
Classification
Removal /Separation
Date you learned of non-selection:
Converted to F/T CC
Reprimand
Duty Hours
Resignation
Training
Evaluation-Appraisal Merit Pay
Retirement
Within Grade Increase
Evaluation-Appraisal Non-Merit Pay
Sex Based Harassment
Working Conditions
EEO Intake (11/03)
Page 1 of 3
EEO COUNSELING – INTAKE INFORMATION
On
, you requested an appointment with an EEO Counselor.
Month, Day, Year
Informal Intake #:
/
/
Facility Abbreviation /
FY
/ Sequential ####
A. Counselee’s Information
Name (Last, First, Middle Initial)
Home Telephone No.
Fax 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
Time in Current Position
_____Years
_____Months
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
Are you a Strategic Business Unit Employee?
Yes
No If the answer is yes, please check the following box to indicate the unit:
Chief Information’s Office
Chief Financial Office
Directors Staff
Manufacturing
Protection
Sales and Marketing
Your Work Telephone No.
Your Email Address
(
)
Your Supervisor’s Name
Supervisor’s Telephone No.
(
)
Supervisor’s Position Title
Series
Grade
Duty Hours
Supervisor’s Email Address
B. Discrimination Basis
Prohibited discrimination includes actions taken based on your Race, Color, Religion, Sex, National Origin, Age (40+), Physical and/or Mental
Disability, or in
Retaliation (for prior EEO activity).
These categories are referred to on this form as basis.
Check and Particularize Each that Applies:
1. Race (Specify):
9. Age (Specify Date of Birth):
2. Color (Specify):
10. Physical Disability (Specify):
3. Religion (Specify):
11. Mental Disability (Specify):
4. Sex (Specify):
12. Reprisal (Dates of prior EEO Activity):
5. Genetic Information
6. Sexual Orientation
7. Parental Status
8. National Origin (Specify):
C. Matter Causing Complaint or Issue
Appointment
Pay
Time & Attendance
Assignment of Duties
Promotion (Provide the following information): Position Title:
Awards
Reassignment
Series & Grade:
Change to Lower Grade
Reinstatement
Announcement Number
Classification
Removal /Separation
Date you learned of non-selection:
Converted to F/T CC
Reprimand
Duty Hours
Resignation
Training
Evaluation-Appraisal Merit Pay
Retirement
Within Grade Increase
Evaluation-Appraisal Non-Merit Pay
Sex Based Harassment
Working Conditions
EEO Intake (11/03)
Page 1 of 3
Exam / Test
Sexual Harassment
Other (Explain)
Harassment
Suspension
Overtime
Termination During Probation
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)
(Factor(s) describing comparative employee, i.e., Race-Black, Sex-Female)
was treated differently than I when:
2.
(Name of Comparative Employee)
(Factor(s) describing comparative employee, i.e., Race-Black, Sex-Female)
was treated differently than I when:
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
EEO Intake (11/03)
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2a. Agency Officials Name
2b. Title, Series and Grade
3a. Agency Officials Name
3b. Title, Series and Grade
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?
Yes
No If yes, ______________
(Date)
(Current Status)
2. Are you a bargaining unit employee?
Yes
No
3. Filed a grievance under the Agency grievance system?
Yes
No If yes, ______________
(Date)
(Current Status)
4. Filed an appeal with the Merit Systems Protection Board?
Yes
No If yes, ______________
(Date)
(Current Status)
I. Anonymity
You have the right to remain anonymous during the counseling process.
Do you desire anonymity?
Yes
No
___________________________________
Signature/Date
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
Representative’s Title
Attorney:
Yes
No
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
Formal complaints are neither anonymous nor confidential. Whether
by The Equal Employment Opportunity Act of 1972; 42 U.S.C.2000e-
or not you file a formal EEO complaint, this form and enclosures, if
16; PL 95-602 as amended; 5USC 1303 and 1304; 5 CFR 5.2 and 5.3;
any, may be used in a depersonalized manner as a data base for
29 CFR 1614.105; the Age Discrimination in Employment Act of
program analysis, review, evaluation, and statistics. If you have not
1967, as amended 29 U.S.C. 633a; the Rehabilitation Act of 1973, as
chosen anonymity and there is a need to disclose information from
amended, 29 U.S.C. 794a; and Executive Order 11478, as amended.
your EEO counseling reports for reasons other than those which have
The information supplied will be used to resolve the EEO counseling
been cited or for reasons cited in the Privacy Act (5USC 522 a (b)),
matter(s) you have raised during counseling. This information may be
your prior consent will be solicited. Disclosure of the information
discussed with designated officers and employees of the Department
sought during counseling is voluntary. However, because issues
in order to resolve the matters you have raised. If you file a formal
raised in a formal complaint must first have been raised at the
EEO complaint, the complaint form, the counseling report form and
counseling stage, the failure to disclose relevant information may
all enclosures will be made part of your EEO complaint file and will
result in dismissal of the formal complaint in whole or in part.
be available to any person having a need to know its contents.
Please Print Your Name Here
Your Signature
Date Signed
EEO Intake (11/03)
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