Va Form 4939 - Complaint Of Employment Discrimination - Department Of Veteran Affairs

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OMB NO.: 2900-0716

EXPIRATION DATE: DEC 31, 2019

COMPLAINT CASE NUMBER:

RESPONDENT BURDEN: 30 Min.

COMPLAINT OF EMPLOYMENT DISCRIMINATION

Read the instructions on the reverse side of this form carefully before completing the front of this form.

1. NAME (Last, first, middle initial)(Please print)

3. MAILING ADDRESS

4a. WORK TELEPHONE NUMBER

(Include Area Code)

2. EMAIL ADDRESS

4b. PRIMARY TELEPHONE NUMBER

(Include Area Code)

6a. JOB TITLE, SERIES AND GRADE

7. NAME AND ADDRESS OF VA FACILITY WHERE

5. ARE YOU:

DISCRIMINATION OCCURRED

A VA EMPLOYEE

AN APPLICANT FOR EMPLOYMENT

6b. SERVICE/SECTION/PRODUCT LINE

A FORMER VA EMPLOYEE

NOTE: For each employment related matter that you believe was discriminatory you must list the bases (list one or more of the following):

Race (Specify), Color (Specify), Religion (Specify), Sex (Male or Female), National Origin (Specify), Age (Provide date of birth),

Disability (Specify), Genetic Information (including family medical history), and/or Reprisal for participating in the EEO process or opposing unlawful discrimination.

9. CLAIM(S)

(What employment related claim(s) - personnel action(s), incident(s), or event(s) caused you to file this complaint?

10. DATE OF

OCCURRENCE

Briefly state the specific claim, personnel action and/or event that caused you to file this complaint.

8. BASIS

(Include the most

Use an additional sheet of paper if necessary. You should not include information that violates the Privacy Act of

recent date(s))

1974 and the Health Insurance Portability and Accountability Act (HIPAA). Some examples are patient medical

records, personal records of other VA-employees, etc.)

11. REMEDIES SOUGHT (Use an additional sheet of paper if necessary.)

12a. DO YOU HAVE A REPRESENTATIVE?

12c. PROVIDE THE NAME AND ADDRESS OF YOUR

12d. TELEPHONE NUMBER

REPRESENTATIVE

(Include Area Code)

YES

12b. IF "YES," IS HE OR SHE AN ATTORNEY?

12e. EMAIL ADDRESS

YES

13a. HAVE YOU CONTACTED AN EEO

13b. NAME OF EEO COUNSELOR

13c. DATE OF INITIAL

COUNSELOR?

CONTACT WITH ORM

YES

14. If you contacted an EEO Counselor more than 45 calendar days after the Date(s) of Occurrence, listed in item 10, or if this complaint is filed more than 15 calendar

days after receipt of a Notice of Right to File a Discrimination Complaint, you must explain why you were untimely in seeking EEO counseling or untimely in filing a

complaint. (Use an additional sheet of paper, if necessary.)

15a. HAVE YOU FILED A UNION

15b. IF "YES," LIST THE CLAIM(S)

16a. HAVE YOU FILED AN APPEAL WITH THE

16b. IF "YES," LIST THE ISSUE(S)

GRIEVANCE ON ANY CLAIM(S)

AND DATE GRIEVANCE FILED

MERIT SYSTEM PROTECTION BOARD

AND DATE MSPB APPEAL FILED.

LISTED ABOVE?

(MSPB) ON ANY OF THE CLAIMS LISTED

ABOVE?