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Management Directive 110

Appendix H EEO-MD-110 EEO COUNSELOR'S REPORT
29 C.F.R. § 1614.105

  1. REQUIRED ELEMENTS
    1. AGGRIEVED PERSON

      Name:_______________________________________________

      Job Title/Series/Grade:_______________________________________________

      Place of Employment:________________________________________________

      Work Phone No.:_________________________

      Home Phone No.:________________________

      Home Address: ___________________________________________________

      ____________________________________________________

      ____________________________________________________

    2. CHRONOLOGY OF EEO COUNSELING

      Date of Initial Contact:

      Solid black line for entry of Date of intital contact.

      Date of Initial Interview:_____________________________________________

      Date of Alleged Discriminatory Event:__________________________________

      45th Day after Event:______________________________________________

      Reason for delayed contact beyond 45 days, if applicable:

      _______________________________________________________________

      _______________________________________________________________

      Date Counseling Report Requested:__________________________________

      Date Counseling Report Submitted:__________________________________

    3. BASIS(ES) FOR ALLEGED DISCRIMINATION

      1) [ ] Race (Specify)_______________________________________

      2) [ ] Color (Specify)______________________________________

      3) [ ] National Origin (Specify)______________________________

      4) [ ] Sex (Male, Female, LGBT)____________________________

      5) [ ] Pregnancy Discrimination______________________________

      6) [ ] Age (Date of Birth)___________________________________

      7) [ ] Mental Disability (Specify)_____________________________

      8) [ ] Physical Disability (Specify)____________________________

      9) [ ] Religion (Specify)____________________________________

      10) [ ] Equal Pay (Specify)__________________________________

      11) [ ] Genetic Information (Specify)___________________________

      12) [ ] Reprisal (Identify earlier event and/or opposed

      practice, give date)____________________________________

    4. PRECISE DESCRIPTION OF THE ISSUE(S) COUNSELED


    5. REMEDY REQUESTED


    6. EEO COUNSELOR'S CHECKLIST - THE EEO COUNSELOR ADVISED THE AGGRIEVED PERSON IN WRITING OF THE RIGHTS AND RESPONSIBILITIES CONTAINED IN THE EEO COUNSELOR CHECKLIST.


  2. SUMMARY OF INFORMAL RESOLUTION ATTEMPTS
    1. IF THE EEO COUNSELOR ATTEMPTED RESOLUTION
      1. Personal Contacts


      2. Documents Reviewed


      3. Summary of Informal Resolution Attempt


    2. IF AGGRIEVED OPTED FOR EEO ADR, EEO COUNSELOR=S STATEMENT THAT THE EEO ADR PROCESS WAS FULLY EXPLAINED TO THE AGGRIEVED INDIVIDUAL/SUMMARY OF INFORMATION GIVEN TO THE AGGRIEVED INDIVIDUAL AND THE AGENCY BY THE EEO COUNSELOR


    _____________________________
    Name of EEO Counselor
    ____________________________
    Telephone Number
    _____________________________
    Signature of EEO Counselor
    ____________________________
    Office Address
    _____________________________
    Date