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Management Directive 110

Appendix G EEO-MD-110
NOTICE OF RIGHT TO FILE A DISCRIMINATION COMPLAINT
(Sample)

SUBJECT: Notice of Right to File a Discrimination Complaint

FROM: EEO Counselor DATE:

TO: (Name of Person Counseled)

This is to inform you that because the dispute you brought to my attention has not been resolved to your satisfaction, you are now entitled to file an individual or class-based discrimination complaint based on race, color, religion, sex, national origin, physical or mental disability, age, genetic information, and/or reprisal. If you file a complaint, it must be in writing, signed, and filed within fifteen (15) calendar days after receipt of this notice, with any of the following officials authorized to receive discrimination complaints:

  • Field Installation Head
    (Provide name and address)
  • Agency Director of Equal Employment Opportunity
    (Provide name and address)
  • Agency Head
    (Provide name, title, and address)
  • Other Official(s) as designated by the Agency, for example, an agency Equal Employment Opportunity Officer, the Hispanic Program Coordinator, the Disability Program Coordinator, or the Federal Women's Program Coordinator
    [Provide name(s) and address(es)]

A complaint shall be deemed timely if it is received or postmarked before the expiration of the 15-day filing period, or in the absence of a legible postmark, if it is received by mail within five days of the expiration of the filing period.

If you file your complaint with one of the officials listed above (other than the EEO Director), it will be sent to the activity's EEO Director for processing. Therefore, if you choose to file your complaint with any of the other officials listed above, be sure to provide a copy of your complaint to the EEO Director to ensure prompt processing of your complaint.

The complaint must be specific and contain only those issues either specifically discussed with me or issues that are like or related to the issues that you discussed with me. It must also state whether you have filed a grievance under a negotiated grievance procedure or an appeal to the Merit Systems Protection Board on the same claims.

If you retain an attorney or any other person to represent you, you or your representative must immediately notify the EEO Director, in writing. You and/or your representative will receive a written acknowledgment of your discrimination complaint from the appropriate agency official.

If you file a complaint, you should name __________ (The EEO Counselor should provide the name and title of the agency head or department head. Agency or department means the national organization, and not just the local office, facility, or department in which the aggrieved person might work.)

_______________________________________
(Signature Block)
EEO Counselor

NOTE:

A copy of this notice must be provided to the EEO Director with the EEO Counselor's Report and will be made a part of the complaint file.

You may contact _________________(provide name and contact information) if a reasonable accommodation is needed to navigate the EEO process.