Fillable Printable VA Form 10192
Fillable Printable VA Form 10192
VA Form 10192
INFORMATION FOR PRE-COMPLAINT PROCESSING
I. REQUESTOR INFORMATION
1. NAME (Last, First, MI) 2. BEST CONTACT TELEPHONE NUMBER
3. MAILING ADDRESS (Street or P.O. Box, City, State, Zip + 4) 4. BUSINESS ADDRESS (Street, City, State, Zip + 4)
5. BUSINESS TELEPHONE NUMBER 6. BEST TIME TO CALL 7. E-MAIL ADDRESS
8. POSITION TITLE/GRADE 9. EMPLOYMENT STATUS (Check one)
EMPLOYEE APPLICANT
FORMER EMPLOYEE
OTHER
10. SERVICE/SECTION/MAIL CODE
II. TYPE OF EMPLOYMENT/VA ORGANIZATION
1a.TYPE OF EMPLOYMENT
TITLE 5
TITLE 38
HYBRID 38
2. EMPLOYMENT
FULL TIME
PART-TIME
3. ORGANIZATION
VHA
VBA
NCA
OIT
CANTEEN
OTHER
4. BARGAINING UNIT EMPLOYE
YES NO
5. NAME OF FACILITY 6. FACILITY ADDRESS 7. FACILITY TELEPHONE NUMBER
III. SENIOR EXECUTIVE SERVICE (SES)
1. ARE YOU SES?
YES NO
2. ARE YOU FILING AGAINST A SES?
NOYES
IV. DESCRIPTION OF ISSUE(S)/CLAIM(S)
1. USE THE SPACE BELOW TO BRIEFLY DESCRIBE THE ISSUE(S) OR ACTION(S) THAT PROMPTED YOU TO SEEK EEO COUNSELING AT THIS TIME.
On __________________________________, _______, __________
(Month) (Day) (Year)
V. DISCRIMINATION FACTORS (BASIS(ES))
Prohibited discrimination includes actions taken based on your Race, Color, Religion, Sex, Age (40 and over), National Origin, Physical and/or Mental Disability, Genetic
Information and/or Retaliation for participating in the EEO process or opposing unlawful discrimination. These categories are referred to on this form as basis(es).
1. WHAT BASIS(ES) OF DISCRIMINATION ARE YOU ALLEGING? (Please be specific, i.e., Race - African American, Sex - Female.)
VA FORM
DEC 2016
10192
OMB Approved No. 2900-0716
Respondent Burden: 30 Minutes
Expiration Date: 12/31/2019
b. __________________________________________________________ ______________________________________________________________________________
(Name of Employee)
(Basis(es) that describe the employee, i.e., sex (male), National Origin (hispanic))
was treated differently than I when:
VII. RESPONSIBLE MANAGEMENT OFFICIAL(S) (RMO)
List the name(s) of the Responsible Management official(s) who took the action(s) which prompted you to seek counseling at this time.
1a. NAME (Last, First, MI) 1b. TITLE
1c. OFFICE 1d. GRADE LEVEL
2a. NAME (Last, First, MI) 2b. TITLE
2c. OFFICE 2d. GRADE LEVEL
3a. NAME (Last, First, MI) 3b. TITLE
3c. OFFICE 3d. GRADE LEVEL
Retaliation Allegations Only:
4. WAS/WERE THE RESPONSIBLE MANAGEMENT OFFICIAL(S) LISTED ABOVE AWARE OF YOUR PRIOR EEO ACTIVITY?
YES (If YES, explain how the official(s) became aware)
NO
VIII. RESOLUTION
1. WHAT ARE YOU SEEKING AS A RESOLUTION TO YOUR PRE-COMPLAINT?
VA FORM
DEC 2016
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VI. COMPARISONS
1. FOR EACH ITEM LISTED IN SECTION IV AND V, PROVIDE WHO YOU BELIEVE YOU WERE TREATED DIFFERENTLY THAN AND WHY.
a. __________________________________________________________ ______________________________________________________________________________
(Name of Employee) (Basis(es) that describe the employee, i.e., sex (male), National Origin (hispanic))
was treated differently than I when:
FOR RETALIATION ALLEGATIONS ONLY:
2. IF YOU ARE ALLEGING RETALIATION DISCRIMINATION, PROVIDE THE DATE(S) AND SPECIFICS OF THE EEO ACTIVITY WHICH YOU FEEL CAUSED YOU TO BE
RETALIATED AGAINST.
a. On __________________________________, _______, __________, I engaged in EEO activity. Case No: __________________________________
(Month) (Day) (Year)
b. On __________________________________, _______, __________, I engaged in EEO activity. Case No: __________________________________
(Month) (Day) (Year)
XV. RESPONDENT BURDEN STATEMENT
In accordance with the Paperwork Reduction Act of 1995, The Department of Veterans Affairs (VA) may not conduct or sponsor, and the respondent is not
required to respond to this collection of information unless it displays a valid OMB Control Number. The valid OMB Control Number for this information
collection is 2900-0716. The collection of this information is voluntary. However, the information is necessary to determine if your complaint of employment
discrimination is acceptable for further processing in accordance with EEOC, 29 C.F.R. §1614. The time required to complete this information collection is
estimated to average 30 (minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing the form. Send comments regarding this burden estimate or any other aspects of this collection, including suggestions for reducing this
burden, to VA Clearance Officer (005R1B), 810 Vermont Avenue, Washington, DC 20420. SEND COMMENTS ONLY. DO NOT SEND THIS FORM, A
COMPLAINT OF EMPLOYMENT DISCRIMINATION, OR REQUEST FOR BENEFITS TO THIS ADDRESS.
PRINT YOUR NAME HERE
YOUR SIGNATURE (Ink signature) DATE SIGNED
PLEASE RETURN THIS FORM TO:
DEPARTMENT OF VETERANS AFFAIRS
OFFICE OF RESOLUTION MANAGEMENT (08)
ATTN: COUNSELOR TEAM LEADER
EMAIL ADDRESS:
DISCLAIMER: Neither the Department of Veterans Affairs (VA) nor the Office of Resolution Management can guarantee the security of the content of external
emails (emails outside of the `va.gov' domain). Encryption offers protection against unintended readers accessing the content of e-mails. VA provides encryption
services to its employees for intra-agency e-mails and requires its use for email containing sensitive, personal information. Currently, VA does not offer encryption
for email accounts outside of the VA network. If you are concerned with the security of your email transmission, we suggest that you mail this form and any
attachments to the mailing address listed above.
VA FORM
DEC 2016
10192
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XIII. REPRESENTATION
You have a right to a representative during the EEO complaint process including during EEO counseling. You may select anyone to represent you, as long as their
positon with VA would not represent a conflict of interest. The EEO counselor cannot be your representative.
1.
I DO NOT WANT A REPRESENTATIVE AT THIS TIME. I UNDERSTAND I MAY SELECT A REPRESENTATIVE LATER (or at any stage of the EEO process).
I HAVE A REPRESENTATIVE
2. NAME OF REPRESENTATIVE 4. ATTORNEY
YES NO
5. ADDRESSS 6. TELEPHONE NUMBER
7. FAX NUMBER
X. DOCUMENTATION
Include a copy of any written action(s) that caused you to seek counseling at this time.
XI. PRIVACY ACT STATEMENT
The collection of this information is authorized by the Equal Employment Opportunity Act of 1972, 42 U.S.C. § 2000e-16; the Age Discrimination in Employment
Act of 1967, as amended, 29 U.S.C. § 633a; the Rehabilitation Act of 1973, as amended, 29 U.S.C. § 794a; and Executive Order 11478, as amended. This
information will be used to adjudicate complaints of alleged discrimination and to evaluate the effectiveness of the EEO program.
XII. AUTHORIZATION
I am aware that this form will be made part of the official informal complaint record and assigned an Office of Resolution Management (ORM) case number. If
the claim(s) contained herein are like or related to a formal complaint that is currently pending with ORM, prior to issuance of the Advisement of Rights letter, the
District Manager will determine if the claim(s) should be processed as an amendment to the pending formal complaint. You will be notified in writing.
IX. MERIT SYSTEM PROTECTION BOARD (MSPB) AND NEGOTIATED GRIEVANCE
ON THE ISSUE(S) THAT PROMPTED YOU TO SEEK EEO COUNSELING, HAVE YOU:
1. FILED A UNION GRIEVANCE ON THE ISSUE?
YES NO
IF YES, DATE
CURRENT STEP:
2. FILED AN MSPB APPEAL ON THIS ISSUE?
YES NO
IF YES, DATE APPEAL FILED:
Signing the enclosed Election to Receive EEO Correspondence via Email will authorize the Office of Resolution Management (ORM) to send you all documents
electronically.
XIV. ELECTION TO RECEIVE EEO CORRESPONDENCE VIA EMAIL
3. EMAIL ADDRESS
