OCR EEO Complaint Submission

General

OMB No: 2105-0556

PAPERWORK REDUCTION ACT BURDEN STATEMENT

Under the Paperwork Act of 1995, no persons are required to respond to a collection of information unless it displays valid OMB control number. The public reporting burden for this voluntary collection of information is estimated to average 1 hour per response. If you wish to comment on the accuracy of the estimate or make suggestions for reducing this burden, please direct your comments to the U.S. Department of Transportation, Departmental Office of Civil Rights, S-30, 1200 New Jersey Avenue, SE, Washington, DC 20590

Please use the above tabs to view and fill out each section of the OMB No: 2105-0556 form.

You must complete the process and receive a confirmation email for your form to be considered.

If you require assistance with this form, please contact DOCR.e-formalfiling@dot.gov

This form should be used only if you, as an applicant for employment with the Department of Transportation, or as a present or former Department of Transportation employee:

believe you have been discriminated against because of your race, color, religion, sex (gender, sexual harassment, pregnancy, or sexual orientation), national origin, age (40 years or older at the time of the event giving rise to your claim), physical or mental disability, equal pay/compensation, genetic information, or believe that you have been retaliated against for participating in activities covered under the Equal Employment Opportunity statutes; and
have presented the matter for informal resolution to an EEO Counselor within 45-calendar days of the event giving rise to your claim, or within 45-calendar days of first becoming aware of the alleged discrimination.

IMPORTANT NOTE: In certain situations, the information provided in Part III of the attached complaint form may be used in lieu of an affidavit in the investigation of your complaint. Accordingly, the information you provide in this part should be brief, clear, and complete.

WHEN TO FILE: In accordance with 29 C.F.R. § 1614.106, your formal complaint must be filed within 15-calendar days of the date you received the Notice of Right to File a Discrimination Complaint form from your EEO Counselor. You must sign and date your complaint. If you are represented by an attorney, the attorney may sign the complaint on your behalf.
These time limits may be extended: 1) if you show that you were not notified of the time limits and were not otherwise aware of them, or 2) if you were prevented by circumstances beyond your control from submitting the matter within the time limits, or 3) for other reasons considered sufficient by the Department.

REPRESENTATION: You may have a representative of your own choosing at all stages of the processing of your complaint. However, your representative will be disqualified if such representation would conflict with the official or collateral duties of the representative. No EEO Counselor or EEO Officer may serve as a representative. (Your representative need not be an attorney, but only an attorney representative may sign the complaint on your behalf.)

WHERE TO FILE: The complaint should be filed with the Associate Director, Compliance Operations Division (S-34), Departmental Office of Civil Rights, 1200 New Jersey Avenue, S.E., W76-401, Washington, DC 20590. Filing instructions are contained in the Notice of Right to File a Discrimination Complaint form which was provided by your EEO Counselor. Keep a copy of the completed complaint form for your records.

Privacy

Privacy Act Statement (5 U.S.C. § 552a, as amended).

AUTHORITY: 42 U.S.C. 2000d et seq., § 12101 et seq., 42 U.S.C. 6101 et seq., 29 U.S.C. 794, 749d; 49 U.S.C. 47113; 42 U.S.C. 12101; 49 CFR Part 23; 49 CFR Part 26, and Executive Order 13160. PURPOSE(S): DOT will use the information collected to respond to Disadvantaged Business Enterprise (DBE) and Airport Concession Disadvantaged Business Enterprise (ACDBE) inquiries and adjudicate appeals.

ROUTINE USES: In accordance with DOT’s system of records notice, DOT/ALL–24 Departmental Office of Civil Rights System, 89 FR 79688 (Sept. 30, 2024), the information provided may be disclosed to the U. S. Department of Justice, including United States Attorney’s Offices, or other Federal agency conducting litigation or in proceedings before any court, adjudicative or administrative body, when it is necessary to the litigation and one of the following is a party to the litigation or has an interest in such litigation. A comprehensive list of routine uses can be found in DOT/ALL 24 and DOT’s General Statement of Routine uses, 75 FR 82138 (Dec. 29, 2010). 77 FR 42796 (July 20, 2012), 84 FR 55222 (Oct. 15, 2019).

DISCLOSURE: Provision of the requested information is voluntary; however, failure to furnish the requested information may result in the denial of a DBE or ACDBE application and an inability of the Department to process an appeal or inquiry from any party.

Part One

7) Certify

Part Two

Part Four

Part Five

Individual Complaint of Employment Discrimination Form DOT F 1050-8

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OMB No: 2105-0556

PAPERWORK REDUCTION ACT BURDEN STATEMENT

General

Privacy Act Statement

Part One: Complainant Identification Information

7) Certify

Part Two: Designation Of Representative

8) Representation

Part Three: Alleged Discriminatory Actions

15) Basis of Action

16. Mark below ONLY the claim(s) you believe were relied on to take the actions described in 17.

Part Four: EEO Counselor Contact

Part Five: Upload Supporting Documents