DD Form 2655 Complaint of Discrimination in the Federal Government

What Is DD Form 2655?

DD Form 2655, Complaint of Discrimination in the Federal Government is a document used to report the complaints of employment discrimination due to sex, religion, race, color, age, pregnancy, national origin, disability, genetic information, or reprisal of all current and former DoD employees and applicants for employment by any Federal agency. This form is also used to document the counselling, investigation and adjudication on the issue.

The Department of Defense (DoD) released the latest version of the form - sometimes incorrectly referred to as the DA Form 2655 - in June 2012 with all previous editions obsolete. Download the latest DD Form 2655 fillable version by clicking the link below.

If a Federal employee or an applicant for employment has been discriminated against, they should present the case to the Equal Employment Opportunity (EEO) Counselor within 45 calendar days since the incident occurred. The complaint (DD Form 2655) should be filed within 15 days after the final interview with the EEO counselor.

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FOR AGENCY USE
COMPLAINT OF DISCRIMINATION IN THE
FEDERAL GOVERNMENT
(This form is subject to the Privacy Act of 1974)
(See Page 3 for Privacy Act Statement and Iinstructions - Please type or print)
1. FULL NAME OF COMPLAINANT (Last, First, Middle Initial)
2. TELEPHONE NUMBER (Include
Area Code)
3. ADDRESS (Street, City, State, and ZIP Code)
a. HOME
(
)
b. OFFICE
(
)
4. FEDERAL OFFICE YOU BELIEVE DISCRIMINATED AGAINST YOU
5. ARE YOU NOW WORKING FOR THE FEDERAL GOVERNMENT?
(Prepare a separate complaint form for each office which you believe
(If answer is "Yes" complete a, b, and c below.)
discriminated against you.)
YES
NO
a. NAME OF OFFICE THAT YOU BELIEVE DISCRIMINATED AGAINST YOU
a. NAME OF AGENCY WHERE YOU WORK
b. ADDRESS OF OFFICE (Street, City, State, and ZIP Code)
b. ADDRESS OF YOUR AGENCY (Street, City, State, and ZIP Code)
c. NAME AND TITLE OF PERSON(S) YOU BELIEVE DISCRIMINATED
c. TITLE AND GRADE OF YOUR JOB
AGAINST YOU (If you know)
6. ELECTION OF REPRESENTATION
7. DATE ON WHICH MOST RECENT
ATTORNEY
NON-ATTORNEY
NO REPRESENTATION
ALLEGED DISCRIMINATION TOOK
a. NAME OF REPRESENTATIVE (If applicable)
PLACE (YYYYMMDD)
b. ADDRESS (Include ZIP Code)
c. TELEPHONE NUMBER (Incl. area code)
d. FAX NUMBER (Incl. area code)
e. E-MAIL ADDRESS
8. CHECK BELOW WHY YOU BELIEVE YOU WERE DISCRIMINATED AGAINST
a. RACE (If so, state your race)
b. COLOR (If so, state your color)
c. RELIGION (If so, state your religion)
d. NATIONAL ORIGIN (If so, state your national origin)
e. SEX (If so, state your sex)
f. AGE (If so, state your age) (See Note 1)
g. DISABILITY (If so, state whether mental or physical)
h. SEXUAL HARASSMENT (If so, state your sex and the sex of the person you believe harassed you)
i. REPRISAL FOR PREVIOUS EEO ACTIVITY (If so, when)
j. GENETIC INFORMATION
k. PREGNANCY
Note 1: Complaints of discrimination because of age apply only to employees or applicants who were at least 40 years of age at the time the
discriminatory action is alleged to have occurred.
9. EXPLAIN IN SPECIFICS HOW YOU BELIEVE YOU WERE DISCRIMINATED AGAINST (treated differently from other employees or applicants)
DUE TO YOUR RACE, COLOR, RELIGION, NATIONAL ORIGIN, SEX, AGE, PREGNANCY, GENETIC INFORMATION, DISABILITY, OR REPRISAL
(For each allegation, please state to the best of your knowledge, information and belief what incident occurred and when the incident occurred.
If you need more space, continue on another sheet of paper.)
DD FORM 2655, JUN 2012
PREVIOUS EDITION IS OBSOLETE.
Page 1 of 3 Pages
Adobe Professional 8.0
FOR AGENCY USE
COMPLAINT OF DISCRIMINATION IN THE
FEDERAL GOVERNMENT
(This form is subject to the Privacy Act of 1974)
(See Page 3 for Privacy Act Statement and Iinstructions - Please type or print)
1. FULL NAME OF COMPLAINANT (Last, First, Middle Initial)
2. TELEPHONE NUMBER (Include
Area Code)
3. ADDRESS (Street, City, State, and ZIP Code)
a. HOME
(
)
b. OFFICE
(
)
4. FEDERAL OFFICE YOU BELIEVE DISCRIMINATED AGAINST YOU
5. ARE YOU NOW WORKING FOR THE FEDERAL GOVERNMENT?
(Prepare a separate complaint form for each office which you believe
(If answer is "Yes" complete a, b, and c below.)
discriminated against you.)
YES
NO
a. NAME OF OFFICE THAT YOU BELIEVE DISCRIMINATED AGAINST YOU
a. NAME OF AGENCY WHERE YOU WORK
b. ADDRESS OF OFFICE (Street, City, State, and ZIP Code)
b. ADDRESS OF YOUR AGENCY (Street, City, State, and ZIP Code)
c. NAME AND TITLE OF PERSON(S) YOU BELIEVE DISCRIMINATED
c. TITLE AND GRADE OF YOUR JOB
AGAINST YOU (If you know)
6. ELECTION OF REPRESENTATION
7. DATE ON WHICH MOST RECENT
ATTORNEY
NON-ATTORNEY
NO REPRESENTATION
ALLEGED DISCRIMINATION TOOK
a. NAME OF REPRESENTATIVE (If applicable)
PLACE (YYYYMMDD)
b. ADDRESS (Include ZIP Code)
c. TELEPHONE NUMBER (Incl. area code)
d. FAX NUMBER (Incl. area code)
e. E-MAIL ADDRESS
8. CHECK BELOW WHY YOU BELIEVE YOU WERE DISCRIMINATED AGAINST
a. RACE (If so, state your race)
b. COLOR (If so, state your color)
c. RELIGION (If so, state your religion)
d. NATIONAL ORIGIN (If so, state your national origin)
e. SEX (If so, state your sex)
f. AGE (If so, state your age) (See Note 1)
g. DISABILITY (If so, state whether mental or physical)
h. SEXUAL HARASSMENT (If so, state your sex and the sex of the person you believe harassed you)
i. REPRISAL FOR PREVIOUS EEO ACTIVITY (If so, when)
j. GENETIC INFORMATION
k. PREGNANCY
Note 1: Complaints of discrimination because of age apply only to employees or applicants who were at least 40 years of age at the time the
discriminatory action is alleged to have occurred.
9. EXPLAIN IN SPECIFICS HOW YOU BELIEVE YOU WERE DISCRIMINATED AGAINST (treated differently from other employees or applicants)
DUE TO YOUR RACE, COLOR, RELIGION, NATIONAL ORIGIN, SEX, AGE, PREGNANCY, GENETIC INFORMATION, DISABILITY, OR REPRISAL
(For each allegation, please state to the best of your knowledge, information and belief what incident occurred and when the incident occurred.
If you need more space, continue on another sheet of paper.)
DD FORM 2655, JUN 2012
PREVIOUS EDITION IS OBSOLETE.
Page 1 of 3 Pages
Adobe Professional 8.0
10. I HAVE DISCUSSED MY COMPLAINT WITH AN EQUAL EMPLOYMENT
11. NAME OF COUNSELOR (If applicable)
OPPORTUNITY COUNSELOR (See instructions)
YES
NO
12. HAVE THE ISSUES IDENTIFIED IN BLOCK 9 BEEN APPEALED TO THE MERIT SYSTEMS PROTECTION BOARD (MSPB) OR FILED UNDER
A UNION NEGOTIATED GRIEVANCE PROCEDURE?
NO
YES (If Yes, complete 12.a., b., and c. below)
a. (X one)
b. DATE FILED (YYYYMMDD)
c. MSPB OR UNION DOCKET NUMBER (If known)
MSPB
UNION NEGOTIATED GRIEVANCE
13. WHAT RELIEF ARE YOU SEEKING TO RESOLVE THIS COMPLAINT? (State specific corrective action desired for each allegation.)
14. LIST NAME(S) OF WITNESS(ES) AND BRIEFLY STATE WHAT INFORMATION WITNESS MAY CONTRIBUTE TO THE INVESTIGATION OF
YOUR COMPLAINT.
15. SIGNATURE OF COMPLAINANT
16. DATE OF THIS COMPLAINT
(YYYYMMDD)
DD FORM 2655, JUN 2012
Page 2 of 3 Pages
Reset
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 136; 29 U.S.C. 791, 792, 793, and 795; DoD Directive 1440.1; and E.O. 12106.
PRINCIPAL PURPOSE(S): To establish case records and document the counseling, investigation, and adjudication of complaints of employment
discrimination brought by applicants and current and former DoD employees against the DoD.
ROUTINE USE(S): Records may be provided to EEO officials, hearing examiners, investigators and arbitrators, or by representatives of the Equal
Employment Opportunity Commission and the courts concerning the complaint and appeal. The Blanket Routine Uses found at
http://dpclo.defense.gov/privacy/SORNs/blanket_routine_uses.html apply to these records. The specific routine uses found at
http://dpclo.defense.gov/privacy/SORNs/govt/EEOCGOVT-1.html also apply to these records.
DISCLOSURE: Voluntary. However, if the individual does not furnish the information requested, processing the complaint may be delayed or
impaired.
READ INSTRUCTIONS CAREFULLY
This form should be used only if you, as an applicant for Federal employment or a Federal employee, think you have been discriminated against
due to race, color, religion, sex, national origin, age, pregnancy, genetic information, disability, or reprisal by a Federal agency and have
presented the matter for informal resolution to an Equal Employment Opportunity Counselor within 45 calendar days of the date the incident
occurred or, if a personnel action, within 45 calendar days of its effective date.
Your complaint must be filed within 15 calendar days of the date of your final interview with the Equal Employment Opportunity Counselor. If
the matter has not been resolved to your satisfaction within 30 calendar days of your first interview with the Equal Employment Opportunity
Counselor and the final counseling interview has not been completed within that time, you have the right to file a complaint at any time
thereafter up to 15 days after the final interview.
These time limits may be extended if you show that you were not notified of the time limits and were not otherwise aware of them, or that you
were prevented by circumstances beyond your control from submitting the matter within the time limits, or for other reasons considered
sufficient by the agency.
If you need help in the preparation of your complaint, you may contact the Equal Employment Opportunity Counselor who provided you with
your initial counseling, or you may secure help from a representative of your choice.
For complaints filed against the Immediate Office of the Secretary of Defense, the Joint Staff and all activities receiving administrative support
from Washington Headquarters Services, the individuals designated to receive complaints are the Equal Employment Opportunity Officer or the
Director, EEO, Office of the Secretary of Defense. Complaints generated within agencies outside the above designated activities must be filed
with that agency's individual designated to receive complaints of discrimination, i.e., the Chief EEO Counselor.
You may have a representative of your own choosing at all stages of the processing of your complaints.
You will have an opportunity to talk with an investigator and present all the facts which you believe show discrimination. The investigator will
not be under the jurisdiction of the head of that part of the agency in which the alleged discrimination took place.
After the investigation of your complaint has been completed, you will be furnished a copy of the Report of Investigation. You will be given an
opportunity to request a hearing, which will be conducted by an Administrative Judge assigned by the Equal Employment Opportunity
Commission (EEOC). The hearing will be held at a convenient time and place. At the hearing, you may present witnesses and other evidence
on your behalf.
The final decision (in writing) will be made by the head of the agency or his or her designee. If a hearing is held on your complaint, the head of
the agency or the designee will review the decision recommended by the Administrative Judge before making a final decision, and will furnish
you with a transcript of the hearing, a copy of the findings, analysis, and recommended action of the Administrative Judge, along with the
agency's final decision letter.
If you are not satisfied with the final agency decision, you have the right to appeal that decision within 30 calendar days after receipt to the Equal
Employment Opportunity Commission, Office of Federal Operations, P.O. Box 77960, Washington, DC 20013.
If your complaint is based on race, color, religion, sex, national origin, pregnancy, genetic information, disability, or reprisal, you may file a civil
action in an appropriate U.S. District Court within 90 days of receipt of the agency's decision or, if you elect to file an appeal with the
Commission, you may still file a civil action in a Federal District Court within 90 days of the Commission's decision if you are dissatisfied with
the decision.
If your complaint is based on race, color, religion, sex, national origin, pregnancy, genetic information, disability, or reprisal, you may file a civil
action in an appropriate U.S. District Court if you have not received a final agency decision within 180 days of filing your complaint with the
agency or if you have not received a final Commission decision within 180 days of filing your appeal with the Commission's Office of Federal
Operations.
DD FORM 2655, JUN 2012
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Download DD Form 2655 Complaint of Discrimination in the Federal Government

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How to Fill out DD Form 2655?

DD Form 2655 instructions are as follows:

  1. The complainant has to provide their name and address (complete with ZIP code) along with their home and office phone numbers in Boxes 1 through 3;
  2. Box 4 requires the information on the Federal office the complainant believes has discriminated against them. This includes the name and address of the office where the discrimination occurred. The name and title of the perpetrator must be reported on the DD 2655 if that information is known to the applicant;
  3. Box 6 is for electing a representative. The complainant can choose an attorney, a non-attorney and to continue without any representation. The chosen representative must be identified and their name, address, phone number and e-mail should be specified in the corresponding boxes;
  4. Box 7 requires the date when the most recent case of discrimination took place. The reason for discrimination should be indicated in box 8. Box 9 provides space for detailed explanation of the case. If the provided space is not enough, the complainant can continue on another sheet of paper;
  5. Box 10 requires specifying whether the complainant has discussed the issue with a EEO counselor. A positive answer requires the name of the counselor in Box 11. Box 12 should indicate whether the issue had been appealed to the Merit Systems Protection Board (MSPB) or filed under a Union Negotiated Grievance Procedure. Positive answers require completing Boxes 12a through 12c;
  6. The corrective action the complainant believes will resolve the case should be provided in Box 13. If there are any witnesses that can assist in the investigation of the case, their names should be listed in Box 14. The complainant must sign and date the form in Boxes 15 and 16;
  7. If the discrimination complaint if filed against the Immediate Office of the Secretary of Defense, the Joint Staff, or other activities that receive administrative support from Washington Headquarters Services, then the completed DD Form 2655 should be submitted to the EEO officer or the Director. Otherwise, the form should be submitted to the personnel authorized to receive this type of complaints in the specific agency.

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