NRC 655, Eeo Counselor'S Report (OMB Submission Copy)ML22123A152 |
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Category:Administrative Form
MONTHYEARML23319A4462023-11-15015 November 2023 NRC 749 Form (OMB Copy)(07-06-2023) Fm ML23227A1742023-10-0202 October 2023 NRC Form 354, Data Report on Spouse ML23227A0392023-08-15015 August 2023 Form 366 OMB Screen Shots (MAP-X) ML23089A2902023-06-28028 June 2023 NRC Form 974 Privacy Act Complaints Form ML23017A1342023-02-22022 February 2023 NRC 629 (OMB Copy) - Authorization for Payment by Credit Card ML23047A4082023-02-16016 February 2023 Final Screen Shots for Foreign Travel Reporting ML22306A0632022-11-15015 November 2022 NRC Form 313A (RSO) for OMB Renewal 2022 ML22306A0642022-11-15015 November 2022 NRC Form 313 for OMB Renewal 2022 ML22306A0612022-11-15015 November 2022 NRC Form 313A(ANP) for OMB Renewal 2022 ML22306A0592022-11-15015 November 2022 NRC Form 313A(AUD) for OMB Renewal 2022 ML22306A0602022-11-15015 November 2022 NRC Form 313A(AUS) for OMB Renewal 2022 ML22306A0582022-11-15015 November 2022 NRC Form 313A(AUT) for OMB Renewal 2022 ML22235A6832022-08-23023 August 2022 NRC 237 (OMB Copy) (08-23-2022) Fm ML21356A0032022-08-0303 August 2022 NRC Form 748, National Source Tracking Transaction Report ML22186A2322022-07-0101 July 2022 NRC 748 Long Form (OMB Copy)(07-01-2022) Fm ML22186A2332022-07-0101 July 2022 NRC 748A Report Source (OMB Copy)(07-01-2022) Fm ML22186A2342022-07-0101 July 2022 NRC 748B Transfer Source (OMB Copy)(07-01-2022) Fm ML22186A2352022-07-0101 July 2022 NRC 748C Receive Source (OMB Copy)(07-01-2022) Fm ML22186A2362022-07-0101 July 2022 NRC 748d Dispose Source (OMB Copy)(07-01-2022) Fm ML22186A2372022-07-0101 July 2022 NRC 748e Manufacture Source (OMB Copy)(07-01-2022) Fm ML22186A2382022-07-0101 July 2022 NRC 748F Import Source (OMB Copy)(07-01-2022) Fm ML22186A2392022-07-0101 July 2022 NRC 748G Export Source (OMB Copy)(07-01-2022) Fm ML22186A2402022-07-0101 July 2022 NRC 748H Disassemble Source (OMB Copy)(07-01-2022) Fm ML22123A1072022-05-17017 May 2022 NRC Form 646, Formal Discrimination Complaint (for OMB Submission) ML22123A1522022-05-17017 May 2022 NRC 655, Eeo Counselor'S Report (OMB Submission Copy) ML21340A0172022-03-0404 March 2022 OMB 3150-0036, NRC Form 830 ML21340A0192022-03-0404 March 2022 OMB 3150-0036, NRC Form 830A (Continuation) ML21340A0202022-03-0404 March 2022 OMB 3150-0036, NRC Form 831 ML21340A1032022-03-0404 March 2022 OMB 3150-0036, NRC from 831A (Continuation) ML20308A4332020-11-0303 November 2020 NRC 782, Complaint Form with Updated Privacy Act Statement ML20224A1672020-10-0606 October 2020 NRC Form 781 (OMB Copy) ML20162A2112020-08-0505 August 2020 OMB 3150-XXXX, (New) NRC Form 149, Ocfo Invitational Traveler Request Form (OMB Copy) ML20066F2032020-05-28028 May 2020 NRC Form 782, Complaint Form ML20126G4692020-05-0505 May 2020 Part 55 Research and Test Reactors Exemption Request 5-4-20 ML20126G4902020-04-29029 April 2020 Part 55 Exemption Request for Power Reactors ML19172A1462019-06-21021 June 2019 NRC 781 (OMB Copy)(06-20-2019) Fm ML19172A1652019-06-21021 June 2019 NRC 782 (OMB Copy)(06-20-2019)FM ML19057A1612019-03-26026 March 2019 NRC Form 361 - Reactor Plant Event Notification Worksheet - (OMB Copy) ML19057A1672019-03-26026 March 2019 NRC 361A (OMB Copy)- Fuel Cycle and Materials Event Notification Worksheet ML19057A1692019-03-26026 March 2019 NRC Form 361N - Non-Power Reactor Event Notification Worksheet - (OMB Copy) ML18269A1402018-12-28028 December 2018 NRC Form 830 - Report of Import ML18269A1412018-12-28028 December 2018 NRC Form 830A - Report of Import Continuation Sheet ML18269A1432018-12-28028 December 2018 NRC Form 831A - Report of Export Continuation Sheet ML18295A5942018-10-22022 October 2018 Draft NRC Form 755, Advance Notification to the NRC of Shipments of Category 1 Quantities of Radioactive Material ML18081A4232018-09-27027 September 2018 Draft NRC Form 361, Reactor Plant Event Notification Worksheet ML18081A4652018-09-27027 September 2018 Draft NRC Form 361A, Fuel Cycle and Materials Event Notification Worksheet ML18081A4912018-09-27027 September 2018 Draft NRC Form 361N, Non-Power Reactor (NPR) Event Notification Worksheet ML18002A4752018-04-20020 April 2018 OMB 3150-0027, NRC Form 7, Application for NRC Export/Import License, Amendment, Renewal, or Consent Request(S) 2023-08-15
[Table view]Some use of "" in your query was not closed by a matching "". Category:NRC
MONTHYEARML23319A4462023-11-15015 November 2023 NRC 749 Form (OMB Copy)(07-06-2023) Fm ML23227A1742023-10-0202 October 2023 NRC Form 354, Data Report on Spouse ML23227A0392023-08-15015 August 2023 Form 366 OMB Screen Shots (MAP-X) ML23089A2902023-06-28028 June 2023 NRC Form 974 Privacy Act Complaints Form ML23017A1342023-02-22022 February 2023 NRC 629 (OMB Copy) - Authorization for Payment by Credit Card ML23047A4082023-02-16016 February 2023 Final Screen Shots for Foreign Travel Reporting ML22306A0632022-11-15015 November 2022 NRC Form 313A (RSO) for OMB Renewal 2022 ML22306A0642022-11-15015 November 2022 NRC Form 313 for OMB Renewal 2022 ML22306A0612022-11-15015 November 2022 NRC Form 313A(ANP) for OMB Renewal 2022 ML22306A0592022-11-15015 November 2022 NRC Form 313A(AUD) for OMB Renewal 2022 ML22306A0602022-11-15015 November 2022 NRC Form 313A(AUS) for OMB Renewal 2022 ML22306A0582022-11-15015 November 2022 NRC Form 313A(AUT) for OMB Renewal 2022 ML22235A6832022-08-23023 August 2022 NRC 237 (OMB Copy) (08-23-2022) Fm ML21356A0032022-08-0303 August 2022 NRC Form 748, National Source Tracking Transaction Report ML22186A2322022-07-0101 July 2022 NRC 748 Long Form (OMB Copy)(07-01-2022) Fm ML22186A2332022-07-0101 July 2022 NRC 748A Report Source (OMB Copy)(07-01-2022) Fm ML22186A2342022-07-0101 July 2022 NRC 748B Transfer Source (OMB Copy)(07-01-2022) Fm ML22186A2352022-07-0101 July 2022 NRC 748C Receive Source (OMB Copy)(07-01-2022) Fm ML22186A2362022-07-0101 July 2022 NRC 748d Dispose Source (OMB Copy)(07-01-2022) Fm ML22186A2372022-07-0101 July 2022 NRC 748e Manufacture Source (OMB Copy)(07-01-2022) Fm ML22186A2382022-07-0101 July 2022 NRC 748F Import Source (OMB Copy)(07-01-2022) Fm ML22186A2392022-07-0101 July 2022 NRC 748G Export Source (OMB Copy)(07-01-2022) Fm ML22186A2402022-07-0101 July 2022 NRC 748H Disassemble Source (OMB Copy)(07-01-2022) Fm ML22123A1072022-05-17017 May 2022 NRC Form 646, Formal Discrimination Complaint (for OMB Submission) ML22123A1522022-05-17017 May 2022 NRC 655, Eeo Counselor'S Report (OMB Submission Copy) ML21340A0172022-03-0404 March 2022 OMB 3150-0036, NRC Form 830 ML21340A0192022-03-0404 March 2022 OMB 3150-0036, NRC Form 830A (Continuation) ML21340A0202022-03-0404 March 2022 OMB 3150-0036, NRC Form 831 ML21340A1032022-03-0404 March 2022 OMB 3150-0036, NRC from 831A (Continuation) ML20308A4332020-11-0303 November 2020 NRC 782, Complaint Form with Updated Privacy Act Statement ML20224A1672020-10-0606 October 2020 NRC Form 781 (OMB Copy) ML20162A2112020-08-0505 August 2020 OMB 3150-XXXX, (New) NRC Form 149, Ocfo Invitational Traveler Request Form (OMB Copy) ML20066F2032020-05-28028 May 2020 NRC Form 782, Complaint Form ML20126G4692020-05-0505 May 2020 Part 55 Research and Test Reactors Exemption Request 5-4-20 ML20126G4902020-04-29029 April 2020 Part 55 Exemption Request for Power Reactors ML19172A1462019-06-21021 June 2019 NRC 781 (OMB Copy)(06-20-2019) Fm ML19172A1652019-06-21021 June 2019 NRC 782 (OMB Copy)(06-20-2019)FM ML19057A1612019-03-26026 March 2019 NRC Form 361 - Reactor Plant Event Notification Worksheet - (OMB Copy) ML19057A1672019-03-26026 March 2019 NRC 361A (OMB Copy)- Fuel Cycle and Materials Event Notification Worksheet ML19057A1692019-03-26026 March 2019 NRC Form 361N - Non-Power Reactor Event Notification Worksheet - (OMB Copy) ML18269A1402018-12-28028 December 2018 NRC Form 830 - Report of Import ML18269A1412018-12-28028 December 2018 NRC Form 830A - Report of Import Continuation Sheet ML18269A1432018-12-28028 December 2018 NRC Form 831A - Report of Export Continuation Sheet ML18295A5942018-10-22022 October 2018 Draft NRC Form 755, Advance Notification to the NRC of Shipments of Category 1 Quantities of Radioactive Material ML18081A4232018-09-27027 September 2018 Draft NRC Form 361, Reactor Plant Event Notification Worksheet ML18081A4652018-09-27027 September 2018 Draft NRC Form 361A, Fuel Cycle and Materials Event Notification Worksheet ML18081A4912018-09-27027 September 2018 Draft NRC Form 361N, Non-Power Reactor (NPR) Event Notification Worksheet ML18002A4752018-04-20020 April 2018 OMB 3150-0027, NRC Form 7, Application for NRC Export/Import License, Amendment, Renewal, or Consent Request(S) 2023-08-15
[Table view]Some use of "" in your query was not closed by a matching "". Category:OMB Clearance Material
MONTHYEARML23332A0442024-01-0808 January 2024 OMB 3150-0158, Draft Federal Register Notice, 10 CFR 36, Licenses and Radiation Safety Requirements for Irradiators ML23223A0162023-11-29029 November 2023 OMB-3150-XXXX Draft Pre-Application Communication and Scheduling for Licensing Actions Related to Digital Instrumentation and Controls - 60-Day FRN ML23318A4302023-11-28028 November 2023 OMB 3150-0006, 30-Day FRN for NRC Form 5 ML23256A1802023-11-21021 November 2023 OMB 3150-XXXX, Final Codes and Standards - 30-day Federal Register Notice ML23319A4462023-11-15015 November 2023 NRC 749 Form (OMB Copy)(07-06-2023) Fm ML23240A3622023-10-17017 October 2023 OMB 3150-0044, 10 CFR Part 19, Draft Supporting Statement ML23270C0192023-10-11011 October 2023 Final 2023 Supporting Statement for 3150-0223 NRC Form 749 LVS ML23227A1732023-10-0202 October 2023 OMB 3150-0026, Draft Supporting Statement for Form 354, Data Report on Spouse ML23227A1742023-10-0202 October 2023 NRC Form 354, Data Report on Spouse ML23156A2412023-09-28028 September 2023 10 CFR Part 63- 60-day Supporting Statement 2023 ML23164A0432023-09-13013 September 2023 OMB Renewal CUI Challenge Request Final Supporting Statement ML23046A1252023-09-0101 September 2023 OMB 3150-0151, Draft 2023 Collection Renewal 10 CFR Part 52, Licenses, Certifications, and Approvals for Nuclear Power Plants - 60-day FRN ML23017A1322023-02-23023 February 2023 OMB 3150-0190 Draft Federal Register Notice, NRC Form 629, Authorization for Payment by Credit Card ML23017A1332023-02-22022 February 2023 OMB 3150-0190 Draft Supporting Statement, NRC Form 629, Authorization for Payment by Credit Card ML23011A2882023-02-21021 February 2023 Final Supporting Statement for 10 CFR Part 25 - Access Authorization (3150-0046) ML22339A0882023-02-13013 February 2023 OMB 3150-0218 Final Federal Register Notice: (NRC-2022-0028) Information Collection: NRC Form 850, Request for Contractor Assignment(S) ML22339A0892023-02-0808 February 2023 OMB 3150-0218 Final Supporting Statement for NRC Form 850 Request for Contractor Assignment(S) ML22206A2212023-01-30030 January 2023 OMB-3150-0035 Draft 2023 Collection Renewal 10 CFR Part 21 Reporting of Defects and Noncompliance - 60 Day FRN ML23023A2362023-01-26026 January 2023 Final Supporting Statement for Form 327 OMB Clearance ML22251A0842023-01-24024 January 2023 Draft Supporting Statement - NRC CUI Information Sharing Agreement ML22318A1272023-01-0303 January 2023 Final OMB Supporting Statement: NRC Form 314 ML22341A0832023-01-0303 January 2023 Final Supporting Statement for NRC Form 277 Request for Visit ML22353A0952022-12-19019 December 2022 Draft Supporting Statement for Privacy Act Complaint Form 974 ML22199A0042022-11-18018 November 2022 OMB-3150-0001, Final Supporting Statement for 10 CFR Part 32, Specific Domestic Licenses to Manufacture or Transfer Certain Item Containing Byproduct Material ML22235A6932022-11-17017 November 2022 OMB 3150-XXXX, Final 2022 New Collection, Scheduling Information for the Licensing of Accident Tolerant, Higher Burnup, and Increased Enrichment Fuels - Supporting Statement ML22301A0032022-11-15015 November 2022 OMB 3150-0165 Final OMB Supporting Statement for NRC Forms 542 and 542A ML22301A0232022-11-15015 November 2022 OMB 3150-0166 Final OMB Supporting Statement: NRC Forms 541 and 541 a ML22301A0502022-11-15015 November 2022 OMB 3150-0164 Final OMB Supporting Statement NRC Forms 540 and 540A ML22306A0582022-11-15015 November 2022 NRC Form 313A(AUT) for OMB Renewal 2022 ML22306A0612022-11-15015 November 2022 NRC Form 313A(ANP) for OMB Renewal 2022 ML22306A0622022-11-15015 November 2022 NRC Form 313A (AMP) for OMB Renewal 2022 ML22306A0562022-11-15015 November 2022 OMB 3150-0120, Final Supporting Statement for NRC Form 313 Application for Materials License, and NRC Forms 313A ML22306A0632022-11-15015 November 2022 NRC Form 313A (RSO) for OMB Renewal 2022 RIS 2009-06, OMB 3150-XXXX, Draft Supporting Statement for NRC Regulatory Issue Summary 2009-06, Revision 1, Importance of Giving the NRC Advance Notice of Intent to Pursue License Renewal2022-11-10010 November 2022 OMB 3150-XXXX, Draft Supporting Statement for NRC Regulatory Issue Summary 2009-06, Revision 1, Importance of Giving the NRC Advance Notice of Intent to Pursue License Renewal ML22153A0362022-09-20020 September 2022 Draft Supporting Statement 2022 - NRC Form 277, Request for Visit (3150-0051) ML22244A0922022-09-0101 September 2022 OMB Screenshot 361 Form, Reactor Plant Event Notification ML22200A1112022-08-26026 August 2022 60-day Federal Register Notice - Information Collection: Access Authorization ML22235A6882022-08-23023 August 2022 NRC 277 (OMB Copy)(08-23-2022) Fm ML22200A1132022-08-23023 August 2022 3150-0046, Draft Burden Tables for 10 CFR Part 25 Information Collection Renewal ML22244A0952022-08-22022 August 2022 OMB Screenshot 361A Form ML22158A0482022-08-16016 August 2022 OMB 3150-XXXX, Draft 2022 New Collection, Scheduling Information for the Licensing of Accident Tolerant, Higher Burnup, and Increased Enrichment Fuels - 60-Day FRN ML22186A2162022-08-16016 August 2022 Final Supporting Statement 10 CFR Part 60 ML22199A2452022-08-12012 August 2022 OMB 3150-0209 Final Supporting Statement for 10 CFR Part 5 ML22195A2622022-08-12012 August 2022 OMB 3150-XXXX, Final Supporting Statement - Nrcareers (Monster Government Solutions) ML22187A2822022-08-0303 August 2022 Final Supporting Statement for Invoice Submissions by Contractors for NRC Contracts/Orders (3150-0109) ML22166A4222022-07-26026 July 2022 OMB 3150-0055, Final 30-day FRN for Information Collection: Safeguards on Nuclear Material, Implementation of Us/Iaea Agreement ML22138A1852022-07-26026 July 2022 OMB 3150-0008, Final Federal Register Notice for 10 CFR Part 71: Packaging and Transportation of Radioactive Material ML22145A6152022-07-19019 July 2022 OMB 3150-0198, Final 30-day FRN, NRC Form 664, General Licensee Registration ML22136A2132022-07-19019 July 2022 Part 37 Burden Tables for 2022 OMB Renewal ML22130A5932022-07-11011 July 2022 30-day FRN for OMB Clearance Renewal of 10 CFR Part 150 2024-01-08
[Table view]Some use of "" in your query was not closed by a matching "". |
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NRC FORM 655 U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-XXXX EXPIRES: (MM/DD/YYYY)
(MM-YYYY) Estimated burden per response to comply with this voluntary collection request: XX hour. NRC requires this information to process allegations of discrimination. Send comments regarding burden estimate to the FOIA, Library, and Information Collections Branch (T-6 EEO COUNSELOR'S REPORT A10M), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by e-mail to Infocollects.Resource@nrc.gov,and the OMB reviewer at: OMB Office of Information and Regulatory Affairs, (3150-XXXX), Attn: Desk Officer for the Nuclear Regulatory Commission, 29 CFR SECTION 1614.105(C) 725 17th Street NW, Washington, DC 20503; e-mail: oira_submission@omb.eop.gov. The NRC may not conduct or sponsor, and a person is not required to respond to, a collection of information unless the document requesting or requiring the collection displays a currently valid OMB control number.
AGGRIEVED PERSON Name and Title Series and Grade Home Telephone Work Telephone Home Address (Number, Street, City, State and Zip Code) Ofc/Div/Brnch Assigned Ofc/Div/Brnch Discrimination Occurred COMPLETE THIS SECTION IF AGGRIEVED PERSON HAS A REPRESENTATIVE Name of Representative Telephone Number Address of Representative (Number, Street, City, State and Zip Code) Is Representative an Attorney?
No Yes CHRONOLOGY OF EEO COUNSELING EFFORT (As applicable)
Date of Initial Contact to Request EEO Counseling: (MM/DD/YYYY)
Date Initial Interview Conducted: (MM/DD/YYYY)
Date of Alleged Discriminatory Incident or Event: (MM/DD/YYYY) 45th Day after Event: (MM/DD/YYYY)
Reason for delayed contact beyond 45 days, if applicable:
Date Aggrieved Signed Rights and Responsibility Package: (MM/DD/YYYY)
Date of Extension Agreement (if any): (MM/DD/YYYY) If an Extension is agreed to, note the not-to-exceed (date):
Date of Election to use ADR: (MM/DD/YYYY)
Date Notified that ADR Completed: (MM/DD/YYYY)
Date of Final Interview: (MM/DD/YYYY)
Date Notice of Right to File a Discrimination Complaint Issued: (MM/DD/YYYY)
Date EEO Counselor's Report Submitted: (MM/DD/YYYY)
BASIS(ES) FOR ALLEGED DISCRIMINATION (Check all that apply)
Race (Specify) Color (Specify)
Religion (Specify) Age (40+) (Specify)
National Origin Mental Disability (Specify) Physical Sex (Including gender Genetic Information identity, sexual orientation and pregnancy)
(Specify)
Equal Pay Prior EEO (Specify) Activity Reprisal/ Opposing Other (Including marital Retaliation policies/
status, parental status, practices political affiliation, made military service) unlawful NRC FORM 655 (MM-YYYY)
Page 1
NRC FORM 655 U.S. NUCLEAR REGULATORY COMMISSION (MM-YYYY)
EEO COUNSELOR'S REPORT 29 CFR SECTION 1614.105(C) (Continued)
ISSUE(S) OF ALLEGED DISCRIMINATION (Check all that apply)
Appointment/Hire Promotion/Non-Selection Assignment of Duties Reassignment (Denied/Directed Reassignment)
Awards Reasonable Accommodation Conversion to Full Time Reinstatement Disciplinary Action - (Specify)
Retirement (Including Constructive Duty Hours Discharge)
Evaluation/Appraisal - PIRM Sex - Stereotyping Examination/Test Termination Sexual Terms/Conditions Employment Harassment Non-Sexual Time and Attendance Medical Examination Training Pay/Including Overtime (Denial WIGI) Other (Specify in box on right)
AGGRIEVED ASSERTS BASIS(ES) NOT COVERED BY EEO REGULATIONS Did the Aggrieved Assert: If yes, the following advisement must be given:
Reprisal for whistle-blowing disclosures is not within the purview or jurisdiction of Federal EEO complaint Reprisal for making whistle-blower disclosures? process. Specific protection is afforded under the Whistle Blower Protection Act through the Office of Special Counsel at the MSPB.
Reprisal for filing a negotiated grievance? Obtain a copy of the grievance from the Aggrieved.
Any other Non-EEO Issue? (Describe in box)
AGGRIEVED WAS ADVISED OF POSSIBLE ELECTIONS (Where applicable)
Request Anonymity
- 1. Aggrieved was advised of his/her right to anonymity during the pre-complaint stage.
Waives Right to Anonymity Not MSPB Matter
- 2. If the matter in dispute is appealable to the MSPB, was the aggrieved person specifically advised of the right to file a Mixed-Case Complaint of a Mixed-Case Appeal, But not both?
Aggrieved Advised Aggrieved Not Covered
- 3. If the aggrieved person is covered by a collective bargaining agreement, was he/she specifically advised of the right to file either a complaint or a grievance, but not both?
Aggrieved Advised
- 4. If the aggrieved person is alleging age discrimination, was he/she specifically advised of the right to by- Not an ADEA Complaint pass the agency complaint process and file a civil action after 30 days notice to the EEOC's Office of Federal Operations? Aggrieved Advised Aggrieved did not Opt ADR
- 5. The Aggrieved Person was fully informed about the availability of ADR?
ADR Opted AGGRIEVED SELECTS ADR Date the Aggrieved elected to pursue mediation: (MM/DD/YYYY)
Date referred to ADR Coordinator: (MM/DD/YYYY)
ADR accepted by management Date:
ADR declined by management NRC FORM 655 (MM-YYYY)
Page 2
NRC FORM 655 U.S. NUCLEAR REGULATORY COMMISSION (MM-YYYY)
EEO COUNSELOR'S REPORT 29 CFR SECTION 1614.105(C) (Continued)
AGGRIEVED SELECTS ADR (Continued)
Date for pre-complaint counseling to conclude [enter date 90 days from date of Initial Interview]:
Date ADR was completed and the outcome (Check One):
Settled during mediation Not resolved during mediation. Date:
Not appropriate for mediation.
Date NRTF Issued/Signed (Check One):
ADR has not been completed: 90 Days have elapsed.
Date:
ADR has been completed: the matter has not settled.
RELIEF REQUESTED NRC FORM 655 (MM-YYYY) Page 3
NRC FORM 655 U.S. NUCLEAR REGULATORY COMMISSION (MM-YYYY)
EEO COUNSELOR'S REPORT 29 CFR SECTION 1614.105(C) (Continued)
COUNSELOR'S INQUIRY INITIAL INTERVIEW WITH AGGRIEVED PERSON (AP)
Name and Title Work Telephone Date (MM/DD/YYYY)
NRC FORM 655 (MM-YYYY)
Page 4
NRC FORM 655 U.S. NUCLEAR REGULATORY COMMISSION (MM-YYYY)
EEO COUNSELOR'S REPORT 29 CFR SECTION 1614.105(C) (Continued)
COUNSELOR'S INQUIRY DOCUMENTS REVIEWED (INCLUDE SOURCE OF DOCUMENTS):
LIST DOCUMENT(S) AND DATE(S)
NRC FORM 655 (MM-YYYY) Page 5
NRC FORM 655 U.S. NUCLEAR REGULATORY COMMISSION (MM-YYYY)
EEO COUNSELOR'S REPORT 29 CFR SECTION 1614.105(C) (Continued)
SUMMARY
OF INTERVIEWS PERSONAL CONTACTS:
Name and Title Work Telephone Date (MM/DD/YYYY)
NRC FORM 655 (MM-YYYY) Page 6
NRC FORM 655 U.S. NUCLEAR REGULATORY COMMISSION (MM-YYYY)
EEO COUNSELOR'S REPORT 29 CFR SECTION 1614.105(C) (Continued)
SUMMARY
OF INFORMAL RESOLUTION ATTEMPT/FINAL INTERVIEW AGGRIEVED PERSON (AP):
Name and Title Work Telephone Date (MM/DD/YYYY)
SIGNATURES Typed or Printed Name of EEO Counselor Work Telephone Signature and Date - EEO Counselor NRC FORM 655 (MM-YYYY) Page 7
NRC FORM 655 U.S. NUCLEAR REGULATORY COMMISSION (MM-YYYY)
EEO COUNSELOR'S REPORT 29 CFR SECTION 1614.105(C) (Continued)
PRIVACY ACT STATEMENT NRC FORM 655, EEO COUNSELOR'S REPORT Pursuant to 5 U.S.C. 552a(e)(3), enacted into law by Section 3 of the Privacy Act of 1974 (Public Law 93-579), the following statement is furnished to individuals who supply information to the U.S. Nuclear Regulatory Commission (NRC) on NRC Form 655. This information is maintained in a system of records designated as EEOC/GOVT-1 Equal Employment Opportunity in the Federal Government Complaint and Appeal Records described at 71 Federal Register 24704 (April 26, 2006).
- 1. AUTHORITY: 42 U.S.C. 2000e-16(b) and (c); 29 U.S.C. 204(f) and 206(d); 29 U.S.C. 633(a); 29 U.S.C. 791; Reorg. Plan No. 1 of 1978, 43 FR 19,607 (May 9, 1978); Exec. Order No. 12106, 44 FR 1053 (Jan. 3, 1979).
- 2. PRINCIPAL PURPOSE(S): To document the complainant's statements in reference to their formal filing of complaint of discrimination based on race, color, national origin, religion, sex (including gender identity, sexual orientation and pregnancy),
age, disability, or reprisal.
- 3. ROUTINE USE(S): In addition to the other types of disclosures permitted under subsection of the Privacy Act, information from this system of records may be disclosed;
- a. To disclose pertinent information to the appropriate federal, state, or local agency responsible for investigating, prosecuting, enforcing, or implementing a statute, rule, regulation, or order, where the disclosing agency becomes aware of an indication of a violation or potential violation of civil or criminal law or regulation.
- b. To disclose information to another federal agency, to a court, or to a party in litigation before a court or in an administrative proceeding being conducted by a federal agency when the government is a party to the judicial or administrative proceeding.
- c. To provide information to a congressional office from the record of an individual in response to an inquiry from that congressional office made at the request of that individual.
- d. To disclose to an authorized appeal grievance examiner, formal complaints examiner, administrative judge, equal employment opportunity investigator, arbitrator or other duly authorized official engaged in investigation or settlement of a grievance, complaint or appeal filed by an employee.
- e. To disclose, in response to a request for discovery or for appearance of a witness, information that is relevant to the subject matter involved in a pending judicial or administrative proceeding.
- f. To disclose information to officials of state or local bar associations or disciplinary boards or committees when they are investigating complaints against attorneys in connection with their representation of a party before EEOC.
- g. To disclose to a Federal agency in the executive, legislative, or judicial branch of government, in response to its request information in connection with the hiring of an employee, the issuance of a security clearance, the conducting of a security or suitability investigation of an individual, the classifying of jobs, or the lawful statutory, administrative, or investigative purpose of the agency to the extent that the information is relevant and necessary to the requesting agency's decision.
- h. To disclose information to employees of contractors engaged by an agency to carry out the agency's responsibilities under 29 CFR part 1614.
- i. To disclose information to potential witnesses as appropriate and necessary to perform the agency's functions under 29 CFR part 1614. For additional details on these routine uses, please see the EEOC/GOVT-1 system notice.
- 4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVIDING INFORMATION: It is voluntary that you furnish the requested information; however, failure to complete all appropriate portions of the form may lead to a delay in processing your request for counseling.
- 5. NRC CONTACT AND ADDRESS INFORMATION: Senior Level Assistant for Policy and Programs, Office of Small Business and Civil, U.S. Nuclear Regulatory Commission, Washington, D.C. 20555-0001.
NRC FORM 655 (MM-YYYY) Page 8