Fillable Printable Formal Complaint Of Discrimination
Fillable Printable Formal Complaint Of Discrimination
Formal Complaint Of Discrimination
10. EXPLAIN WHEN AND HOW YOU WERE DISCRIMINATED AGAINST (If your complaint involves more than one basis of alleged discrimination, list
and number each basis separately and provide specific factual information in support of each allegation of discrimination. If necessary, continue on
page 2.)
1. NAME (
Last, First, Middle Initial)
2. SOCIAL SECURITY NUMBER 3. HOME TELEPHONE NUMBER
4. HOME ADDRESS
6. NAME OF AGENCY WHERE CURRENTLY EMPLOYED
8. CURRENT JOB TITLE
7. PAY PLAN/SERIES/GRADE 6b. EMPLOYER'S ADDRESS
(Complete information to include office symbol).
6a. WORK TELEPHONE NUMBER
PAGE 1 OF 3
FORMAL COMPLAINT OF DISCRIMINATION
For use of this form, see AR 690-600; the proponent agency is OSA
5. DO YOU CURRENTLY WORK FOR THE FEDERAL
GOVERNMENT?
SECTION I - COMPLAINT INFORMATION
REPLACES DA FORM 2590-R, AUG 89, WHICH IS OBSOLETE.
DA FORM 2590, FEB 2004
APD LC v1.01ES
9. REASON YOU BELIEVE YOU WERE DISCRIMINATED AGAINST
(Check below all that apply. Identify specific race, color, sex, age, religion, national
origin, and/or disability.)
PRIVACY ACT STATEMENT (5 U.S.C. ยง552a)
AUTHORITY:
PRINCIPAL PURPOSE:
ROUTINE USES:
DISCLOSURE:
Public Law 92-261
Used for formal filing of complaints of discrimination because of race, color, national origin, religion, sex, age, physical or
mental disability, and/or reprisal by Department of the Army civilian employees, former employees, applicants for
employment, and some contract employees.
Information will be used (a) as a data source for complaint information for production of summary descriptive statistics and
analytical studies of complaints processing and resolution efforts; (b) to respond to general requests for information under
the Freedom of Information Act; (c) to respond to requests from legitimate outside individuals or agencies (Congress, White
House, Equal Employment Opportunity Commission) regarding the status of an EEO complaint or appeal; or (d) to
to adjudicate an EEO complaint or appeal.
Voluntary, however, failure to complete all appropriate portions of the form may lead to rejection of complaint on the basis of
inadequate data on which to continue processing.
RACE COLOR
DISABILITY Mental Physical
NATIONAL ORIGIN RELIGION
AGE
DATE OF BIRTH
SEX Male Female
REPRISAL
(Date(s) and type of prior EEO activity)
NO YES
(If yes, complete 6, 6a, 6b, 7 and 8.)
16. LIST NAME(
s)
OF WITNESS (
ES)
AND BRIEFLY STATE WHAT INFORMATION WITNESS MAY CONTRIBUTE TO THE INVESTIGATION OF
YOUR COMPLAINT.
14. WHAT RELIEF ARE YOU SEEKING TO RESOLVE THIS COMPLAINT?
(State specific corrective action desired for each allegation.)
12b. NAME OF EEO COUNSELOR 12c. DATE OF INITIAL CONTACT WITH EEO
OFFICIAL
(YYYYMMDD)
15c. DATE FILED
(YYYYMMDD)
15d. MSPB OR UNION
DOCKET NUMBER
(If known)
11a. NAME OF ORGANIZATION WHERE ALLEGED DISCRIMINATION
OCCURRED
11b. ADDRESS OF ORGANIZATION WHERE ALLEGED
DISCRIMINATION OCCURRED
17a. SIGNATURE OF COMPLAINANT 17b. DATE DA FORM 2590 SIGNED BY COMPLAINANT
(YYYYMMDD)
EXPLAIN WHEN AND HOW YOU WERE DISCRIMINATED AGAINST
(Cont'd) (If necessary, additional sheets may be used.)
PAGE 2 OF 3
DA FORM 2590, FEB 2004
APD LC v1.01ES
15a. HAVE THE ISSUES IDENTIFIED IN BLOCK 10 BEEN APPEALED TO THE MERIT SYSTEMS PROTECTION BOARD
(MSPB)
OR FILED
UNDER A UNION NEGOTIATED GRIEVANCE PROCEDURE? NO YES (If yes, complete 15b, 15c, and 15d below.)
ATTORNEY NON-ATTORNEY
NAME OF REPRESENTATIVE
ADDRESS
TELEPHONE NUMBER:
NO REPRESENTATION
FAX: E-MAIL:
13. ELECTION OF REPRESENTATION
12d. DATE NOTICE OF RIGHT TO FILE A
FORMAL COMPLAINT OF DISCRIMINATION
RECEIVED
(YYYYMMDD)
12a. HAVE YOU DISCUSSED THE ISSUE (s) IN BLOCK 10 WITH AN EEO COUNSELOR?
NO YES (
If yes, complete 12b,
12c, and 12d below.)
15b.
MSPB UNION NEGOTIATED GRIEVANCE
APPOINTMENT/HIRE
ASSIGNMENT OF DUTIES
CONVERSION TO FULL TIME
DETAIL
DEMOTION
DISCIPLINARY ACTION
(other)
DUTY HOURS
EXAMINATION/TEST
EVALUATION/APPRAISAL
REINSTATEMENT
REPRIMAND
HARASSMENT (
sexual)
PAY/OVERTIME
PROMOTION/NON-SELECTION
REASSIGNMENT-REQUEST DENIED
REASSIGNMENT-DIRECTED
SUSPENSION
TERMINATION
TIME AND ATTENDANCE
TRAINING
TERMS/CONDITIONS OF EMPLOYMENT
18a. NAME OF COMPLAINANT 18b. SOCIAL SECURITY NUMBER 18c. DA DOCKET NUMBER
18d. TYPED/PRINTED NAME OF EEOO 18e. ADDRESS OF EEO OFFICE (
Complete address to include office symbol)
18i. SIGNATURE OF EEOO
18f. EEOO TELEPHONE NUMBER
18g. EEO OFFICE FAX NUMBER
18h. EEOO E-MAIL ADDRESS
19d. DATE COMPLAINT ACCEPTED OR DISMISSED
(YYYYMMDD)
19c. DATE COMPLAINT DEEMED FILED
(YYYYMMDD)
21. REMARKS
19a. DATE COMPLAINT RECEIVED
(YYYYMMDD)
MAIL
(postmark date)
PAGE 3 OF 3
SECTION II - TO BE COMPLETED BY THE PROCESSING EEO OFFICER
(EEOO)
AWARDS
20. IDENTIFY ISSUES IN BLOCK 10 BY PLACING AN "A" FOR ACCEPTED OR A "D" FOR DISMISSED IN APPLICABLE BOX
(es)
HARASSMENT
(non-sexual)
RETIREMENT/CONSTRUCTIVE
DISCHARGE/RESIGNATION
OTHER
(Specify)
DA FORM 2590, FEB 2004
APD LC v1.01ES
19b. METHOD OF DELIVERY
IN PERSON
FAX OTHER
(YYYYMMDD)
