ML21160A151
| ML21160A151 | |
| Person / Time | |
|---|---|
| Issue date: | 02/01/2022 |
| From: | NRC/OGC |
| To: | |
| Erin Deeds | |
| Shared Package | |
| ML21160A142 | List: |
| References | |
| Download: ML21160A151 (8) | |
Text
NRC FORM 655 U.S. NUCLEAR REGULATORY COMMISSION (MM-YYYY)
EEO COUNSELOR'S REPORT 29 CFR SECTION 1614.105(C)
NRC FORM 655 (MM-YYYY)
Page 1 of 8 APPROVED BY OMB: NO. 3150-XXXX EXPIRES: (MM/DD/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 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, 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.
GO TO PRIVACY ACT STATEMENT 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 Alleged Discriminatory Incident or Event: (MM/DD/YYYY)
Date of Initial Contact to Request EEO Counseling: (MM/DD/YYYY)
Date Initial Interview Conducted: (MM/DD/YYYY)
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)
Race (Specify)
Color (Specify)
Religion (Specify)
National Origin (Specify)
Sex (including gender identity, sexual orientation and pregnancy)
Age (40+) (Specify)
Disability Reprisal Appointment/Hire Assignment of Duties Awards Conversion to Full Time Disciplinary Action - (Specify)
Duty Hours Evaluation/Appraisal - PIRM Examination/Test Harassment Sexual Non-Sexual Medical Examination Pay/Including Overtime (Denial WIGI)
Promotion/Non-Selection Reassignment (Denied/Directed Reassignment)
Reasonable Accommodation Reinstatement Retirement (Including Constructive Discharge)
Termination Terms/Conditions Employment Time and Attendance Training Other (Specify in box on right)
Sex - Stereotyping AGGRIEVED PERSON BASIS(ES) FOR ALLEGED DISCRIMINATION (Check all that apply)
ISSUE(S) OF ALLEGED DISCRIMINATION (Check all that apply)
Mental Physical
NRC FORM 655 U.S. NUCLEAR REGULATORY COMMISSION (MM-YYYY)
EEO COUNSELOR'S REPORT 29 CFR SECTION 1614.105(C)
NRC FORM 655 (MM-YYYY)
Page 2 of 8 If yes, the following advisement must be given:
Reprisal for whistle-blowing disclosures is not within the purview or jurisdiction of Federal EEO complaint process. Specific protection is afforded under the Whistle Blower Protection Act through the Office of Special Counsel at the MSPB.
Obtain a copy of the grievance from the Aggrieved.
- 1.
Aggrieved was advised of his/her right to anonymity during the pre-complaint stage.
Request Anonymity Waives Right to Anonymity
- 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?
Not MSPB Matter Aggrieved Advised
- 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 Not Covered Aggrieved Advised
- 4.
If the aggrieved person is alleging age discrimination, was he/she specifically advised of the right to by-pass the agency complaint process and file a civil action after 30 days notice to the EEOC's Office of Federal Operations?
Not an ADEA Complaint Aggrieved Advised
- 5.
The Aggrieved Person was fully informed about the availability of ADR?
Aggrieved did not Opt ADR ADR Opted Date the Aggrieved elected to pursue mediation: (MM/DD/YYYY)
Date referred to ADR Coordinator: (MM/DD/YYYY)
ADR accepted by management ADR declined by management Date:
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.
Not appropriate for mediation.
Date:
Date NRTF Issued/Signed (Check One):
ADR has not been completed: 90 Days have elapsed.
ADR has been completed: the matter has not settled.
Date:
RELIEF REQUESTED Reprisal for making whistle-blower disclosures?
Reprisal for filing a negotiated grievance?
Any other Non-EEO Issue? (Describe in box)
AGGRIEVED WAS ADVISED OF POSSIBLE ELECTIONS (Where applicable)
AGGRIEVED SELECTS ADR Did the Aggrieved Assert:
AGGRIEVED ASSERTS BASIS(ES) NOT COVERED BY EEO REGULATIONS
NRC FORM 655 U.S. NUCLEAR REGULATORY COMMISSION (MM-YYYY)
EEO COUNSELOR'S REPORT 29 CFR SECTION 1614.105(C)
NRC FORM 655 (MM-YYYY)
Page 3 of 8 COUNSELOR'S INQUIRY INITIAL INTERVIEW WITH AGGRIEVED PERSON (AP)
Name and Title Work Telephone Date (MM/DD/YYYY)
NRC FORM 655 U.S. NUCLEAR REGULATORY COMMISSION (MM-YYYY)
EEO COUNSELOR'S REPORT 29 CFR SECTION 1614.105(C)
NRC FORM 655 (MM-YYYY)
Page 4 of 8 COUNSELOR'S INQUIRY INITIAL INTERVIEW WITH AGGRIEVED PERSON (AP) (Continued)
NRC FORM 655 U.S. NUCLEAR REGULATORY COMMISSION (MM-YYYY)
EEO COUNSELOR'S REPORT 29 CFR SECTION 1614.105(C)
NRC FORM 655 (MM-YYYY)
Page 5 of 8 COUNSELOR'S INQUIRY DOCUMENTS REVIEWED (INCLUDE SOURCE OF DOCUMENTS):
DOCUMENTS DATE
NRC FORM 655 U.S. NUCLEAR REGULATORY COMMISSION (MM-YYYY)
EEO COUNSELOR'S REPORT 29 CFR SECTION 1614.105(C)
NRC FORM 655 (MM-YYYY)
Page 6 of 8
SUMMARY
OF INTERVIEWS PERSONAL CONTACTS:
Name and Title Work Telephone Date (MM/DD/YYYY)
NRC FORM 655 U.S. NUCLEAR REGULATORY COMMISSION (MM-YYYY)
EEO COUNSELOR'S REPORT 29 CFR SECTION 1614.105(C)
NRC FORM 655 (MM-YYYY)
Page 7 of 8
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 Date
NRC FORM 655 U.S. NUCLEAR REGULATORY COMMISSION (MM-YYYY)
EEO COUNSELOR'S REPORT 29 CFR SECTION 1614.105(C)
NRC FORM 655 (MM-YYYY)
Page 8 of 8 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.
- 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.
- 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.
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