ML19172A165

NRC 782 (OMB Copy)(06-20-2019)FM

ML19172A165
Person / Time
Issue date:	06/21/2019
From:	NRC/OCIO
To:
Shared Package
ML19169A151	List: ML19169A155 ML19172A146 ML19172A165
References
Download: ML19172A165 (6)

Text

NRC FORM 782 (MM-YYYY)U.S. NUCLEAR REGULATORY COMMISSION OFFICE OF SMALL BUSINESS AND CIVIL RIGHTS OUTREACH AND COMPLIANCE COORDINATION PROGRAM COMPLAINT FORM APPROVED BY OMB: NO. 3150-0053 EXPIRES: (MM/DD/YYYY)

Estimated burden per response to comply with this mandatory collection request: 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br />. NRC requires this information to process allegations of discrimination.

Send comments regarding burden estimate to the Information Services Branch (T-6 A10M), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by e-mail to Infocollects.Resource@nrc.gov, and to the Desk Officer, Office of Information and Regulatory Affairs, NEOB-10202, (3150-0053), Office of Management and Budget, Washington, DC 20503. If a means used to impose an information collection does not display a currently valid OMB control number, the NRC may not conduct or sponsor, and a person is not required to respond to, the information collection.

This form is to be used to file complaints against NRC conducted and Federal financially assisted programs and activities that fall under one of more of the following Federal legislative mandates:

Title VI of the Civil Rights Act of 1964 (race, color, national origin); Title IX of the Education Amendments of 1972 (sex); Section 504 of the Rehabilitation Act of 1973 (disability);

Title IV of the Energy Reorganization Act of 1974 (sex); The Age Discrimination Act of 1975 (Age); and Executive Orders related to providing equal and meaningful access to programs for Limited English proficient persons; access and participation in NRC Federal Education and Training Programs; and Environmental Justice. Under these provisions individuals in the protected classifications cannot be denied access, participation in, or benefits from NRC conducted or Federal financially assisted programs and activities, or otherwise be subjected to discrimination.

(1) *Contact Person Name, Address, City, State & Zip Code, Telephone Number (Home), Telephone Number (Work), (Include area code):

(2) *Person(s) discriminated against, if different from person filing complaint: Address, City, State & Zip Code, Telephone Number (Home), Telephone Number (Work) (Include area code):

(3) *Agency and department or program that discriminated against you: Agency name, Address, Name of Individual if known:

(4A) *Non-employment: Does your complaint concern discrimination in

the delivery of services or in other discrimination actions of the department or agency in its treatment of you or others? If so, please indicate below the basis on which you believe these discriminatory actions were taken.

Race Color National Origin Sex Disability Religion Age Sexual Orientation Status as a Parent (4B) *Employment: Does you complaint concern discrimination in employment by the department or agency? If so, please indicate

below the base(s) on which you believe these discriminatory actions

were taken.

Race Color National Origin Sex Disability Religion Age Sexual Orientation Status as a Parent (5) What is the most convenient method and time (telephone, e-mail, other;

time day/night, between the hours of and ) for us to contact

you about this complaint?

I Can Be Reached

Between the Hours of:

AM PM and: AM PM Telephone Number E-mail Address Other (6) *If we are not able to reach you directly, is there an alternate contact

for information on the complaint?

No Yes (If yes, what is the name and telephone number?)

Name Telephone Number NRC FORM 782 (MM-YYYY)

Page 1 of 5 NRC FORM 782 (MM-YYYY)U.S. NUCLEAR REGULATORY COMMISSION COMPLAINT FORM (Continued)

(7) *Your attorney information, if applicable:

NRC FORM 782 (MM-YYYY)

Page 2 of 5 (8) *To your best recollection, on what date(s) did the alleged discrimination take place?

Earliest date of discrimination (MM/DD/YYYY)

Most recent date of discrimination (MM/DD/YYYY)

(9) *Complaints of discrimination must generally be filed within 180 days of the alleged discrimination. If the most recent date of discrimination, listed above, is more than 180 days ago, you may request a waiver of the filing requirement. If you wish to request a waiver, please explain

why you waited until now to file your complaint.

(10) *Please explain as clearly as possible what happened, why you believe it happened, and how you were discriminated against. Indicate who was

involved. Be sure to include how other persons were treated differently from you. (Please use additional sheets, if necessary and attach a copy

of written materials pertaining to your case.)

(11) Civil Rights laws prohibit reprisal for filing complaints or opposing practices prohibited by these laws. If you have been subjected to retaliation

or intimidation (separate from the discrimination alleged in #10), please explain below including the actions you believe to be the basis for the

reprisal.

NRC FORM 782 (MM-YYYY)U.S. NUCLEAR REGULATORY COMMISSION COMPLAINT FORM (Continued)

(12) *Please list below any persons (witnesses, fellow participants or employees, supervisors, or others), if known, for additional information regarding your complaint.

No.Name Address Telephone Number (Include area code) and E-mail Address What information or documentation will the individual be able to provide to support your complaint?

1 2 3 4 5 (13) Do you have any other information that you think is relevant to our investigation of your allegations?

(14) What remedy are you seeking for the alleged discrimination?

(15) *Have you (or the person discriminated against) filed the same or any other complaints with NRC, another Federal agency, or the recipient

company?

No Yes NRC FORM 782 (MM-YYYY)

Page 3 of 5 If yes, provide the complaint number.

What was the date of that filing? (MM/DD/YYYY)

What is the name of the agency/department or program that the complaint was filed against? (Please provide the address, zip code and phone no.)

NRC FORM 782 (MM-YYYY)U.S. NUCLEAR REGULATORY COMMISSION COMPLAINT FORM (Continued)

Briefly state what the complaint was about?

What were the results?

Cause Finding No Cause Finding Other: (Explain)

(16) *Have you (or the person discriminated against) filed the same or any other complaints with NRC, another Federal agency, or the recipient company?

U.S. Department of Justice U.S. Office of Health and Human Services U.S. Equal Employment Opportunity Commission Federal or State Court Your State of local Human Relations/Rights Commission Other Grievance or Complaint office (17) *If you have already filed a complaint with an agency indicated in #16, please provide the following information (attach pages if necessary).

Name of Agency:

Date filed (MM/DD/YYYY):

Case or Docket Number:

Date of Trial/Hearing (MM/DD/YYYY):

Location of Agency/Court:

Name of Investigator:

Status of Case:

Comments: NRC FORM 782 (MM-YYYY)

Page 4 of 5 NRC FORM 782 (MM-YYYY)U.S. NUCLEAR REGULATORY COMMISSION COMPLAINT FORM (Continued)

(18) If you know of any NRC funds or other assistance received by the program or department in which the alleged discrimination occurred, please provide that information below:

(19) *REQUIRED SIGNATURE

We cannot accept a complaint, if it has not been signed. Please type in your signature and date below. (Signature)

Complainant's signature acknowledges and verifies Date (MM/DD/YYYY)

(20) *REQUIRED SIGNATURE/CONSENT

Your signature below indicates your consent to disclosure of your name during the investigation processes. (If

you are filing this complaint for a person whom you allege has been discriminated against, we will need consent from that person). (Signature)

Complainant's signature acknowledges and verifies consent to release Complainant's name in the course of any Investigation by NRC.

Date (MM/DD/YYYY)

For Questions, please call: (301) 415-7380

U. S. Nuclear Regulatory Commission

The Office of Small Business and Civil Rights YOU MAY SAVE A COPY OF THIS COMPLETED FORM FOR YOUR RECORDS OR PRINT

A COPY, BEFORE YOU CLICK THE SUBMIT BUTTON.

TO SUBMIT YOUR REQUEST BY EMAIL, PRESS THE SUBMIT BUTTON BELOW.

NRC FORM 782 (MM-YYYY)

Page 5 of 5 PRIVACY ACT STATEMENT NRC FORM 782 Complaint Form 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 782. This information is maintained in a system of records designated as NRC-9 and described at 81 Federal Register 81327 (November 17, 2016), or the most recent Federal Register publication of the NRC's Systems of Records Notices that is located in NRC's Agencywide Documents Access and Management System (ADAMS).

1. AUTHORITY:

5 U.S.C. 2301, 2302; 29 U.S.C. 206(d), as amended; 29 U.S.C. 633a, as amended; 29 U.S.C. 791; 42 U.S.C. 1981; 42 U.S.C. 2000e-16, as amended; 42 U.S.C. 5891; Executive Order (E.O.) 11246 as amended; E.O. 11478 as amended; E.O. 12086, as amended by E.O. 12608, as

amended by E.O. 12608; E.O. 12106; E.O. 13166; 10 CFR part 4 and part 5; 29 CFR part 1614.

2. PRINCIPAL PURPOSE(S):

Filing complaints against NRC conducted and Federal financially assisted programs and activities.

3. ROUTINE USE(S):

Information may be furnished to Equal Employment Opportunity Commission, Office of Personnel Management, Merit Systems Protection Board, Department of Justice, Department of Education, Department of Health and Human Services, Office of Management and Budget, and

Congress, under applicable requirements. Information may be disclosed in accordance with any of the

Routine Uses listed in the Prefatory Statement of General Routine Uses, including to an appropriate

Federal, State, local or Foreign agency in the event the information indicates a violation or potential

violation of law; in the course of an administrative or judicial proceeding; to an appropriate Federal, State, local and foreign agency to the extent relevant and necessary for an NRC decision about you or

to the extent relevant and necessary for that agency's decision about you; in the course of discovery

under a protective order issued by a court of competent jurisdiction, and in presenting evidence; to a

Congressional office to respond to their inquiry made at your request; to NRC-paid experts, consultants, and others under contract with the NRC, on a need-to-know basis; or to appropriate

persons and entities for purposes of response and remedial efforts in the event of a suspected or

confirmed breach of data from this system of records.

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 dismissal or delay in processing of

your complaint because of insufficient data on which to evaluate the complaint.

5. SYSTEM MANAGER(S) AND ADDRESS:

Associate Director, Civil Rights and Diversity Directorate and Associate Director, Small Business Outreach and Compliance Directorate, Office of Small Business and Civil Rights, U.S. Nuclear Regulatory Commission, Washington, D.C. 20555-0001.