Fillable Va Form 4939 - Complaint Of Employment Discrimination (Page 2 of 2) in pdf

COMPLAINT OF EMPLOYMENT DISCRIMINATION INSTRUCTIONS

Read the following instructions carefully before you complete this form. Please complete all items on the complaint form.

GENERAL: Pursuant to the Equal Employment Opportunity Commission (EEOC) Title 29 Code of Federal Regulations (CFR) §1614, VA Form

4939, Complaint of Employment Discrimination, can be used by VA employees, former employees and applicants for employment who file a formal

Equal Employment Opportunity (EEO) complaint of discrimination. This regulation prohibits discrimination based on race, color, religion, gender

(sex), national origin, age (40 years and over), physical or mental disability, genetic information, and/or reprisal for prior EEO activity.

You can obtain assistance from your EEO Counselor in filling out this form. Your EEO Counselor can also answer any questions you may have

about this form. In item 8, you should specify the basis of your complaint: race, color, religion, gender (sex), national origin, age (date of birth),

physical or mental disability (specific information about your disability), genetic information, and/or reprisal for prior EEO activity. If you list

"Reprisal," please state the nature of the prior EEO activity in which you were engaged, i.e. did you file a prior EEO complaint? Use an additional

sheet of paper, if necessary.

It is very important that you be precise as to the dates of all actions or events you are protesting. In addition, the claims listed in item 9, must be

limited to those claims discussed with an EEO Counselor (discussed within 45 calendar days of occurrence of the event, or within 45 calendar days

of the effective date, if a personnel action) or like or related claims. If any of the claims listed in item 9 were discussed with an EEO Counselor, but

not within 45 calendar days of their occurrence or of their effective date, you must explain why you waited more than 45 calendar days. If any of the

claims listed in item 9 were not discussed with an EEO Counselor, please contact the Office of Resolution Management (ORM), Regional EEO

Officer IMMEDIATELY. The requirement that you contact an EEO Counselor about every claim listed in item 9 will not be waived under any

circumstances. Failure to do so will only delay the processing of your complaint.

It is your responsibility to keep the (ORM) informed of your current address. If you move, immediately advise the ORM Field Office where you

filed this complaint of your new address. In addition, you may receive certified and express mail in connection with your complaint. It is your

responsibility to claim all certified and express mail. Failure to notify ORM of a change in address or to claim certified and express mail may lead to

dismissal of your complaint.

REPRESENTATION: You may have a representative of your own choosing at all stages of the processing of your complaint. No EEO Counselor,

EEO Investigator 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.)

WHEN TO FILE: Your formal complaint must be filed within 15 calendar days of the date you received the "Notice of Right to File a

Discrimination Complaint" (NRTF) from your EEO Counselor. If you do not meet this time limit, you must explain why you waited more than 15

calendar days to file. These time limits may be extended under certain circumstances; however, they will NOT be waived and your complaint will

NOT be investigated unless you explain your untimeliness and the explanation is acceptable in accordance with EEOC, CFR §1614(c), . Use an

additional sheet of paper, if necessary. If you have evidence, which supports your explanation, please attach it to this complaint.

WHERE TO FILE: The complaint should be filed with the ORM Field Office identified in the NRTF or the Deputy Assistant Secretary for ORM.

You may submit a copy either by mail, in person, electronically (via e-mail), or by facsimile. Filing instructions are contained in the cover letter

attached to the NRTF.

PRIVACY ACT STATEMENT: Maintenance and disclosure of VA Form 4939 is made in accordance with the Privacy Act of 1974. Collection

of the information on this form is authorized and/or required by the regulations of the EEOC, CFR §1614. All records, from which information is

retrieved, by the name or personal identifier of a respondent, are maintained by a Government-wide Systems of Records: EEOC/GOVT-1, Equal

Employment Opportunity Complaint Records and Appeal Records. The information collected will be used by ORM to determine whether your

complaint is acceptable for investigation and in connection with any subsequent investigation and processing of your complaint. In the course of any

investigation, this form may be shown to any individual who may be required by regulations, policies or procedures of the EEOC and/or ORM to

provide information in connection with this complaint, including individuals you may have identified as responsible for the acts or events at issue in

this complaint. Other disclosures may be: (a) to respond to a request form from a Member of Congress regarding the status of the complaint or

appeal; (b) to respond to a court subpoena and/or to refer to a district court in connection with a civil suit; (c) to disclose information to authorized

officials or personnel to adjudicate a complaint or appeal; or (d) to disclose information to another Federal agency or to a court or third party in

litigation when the Government is party to a suit before the court.

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, CFR §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

REVERSE OF VA FORM 4939, MAR 2013

Va Form 4939 - Complaint Of Employment Discrimination Page 2

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