Intake Form A

Date:

*Name:

Home Phone:

Work Phone:

Cell Phone:

*Email Address:

Referred By:

1. What Agency Is Your Claim Against? (Please specify what Department it is organized under):

2. Position:

Salary:

Grade:

3. How long have you worked at that agency?

How long have you worked for the federal government?

4. Are you being subject to a personnel action? (for example, leave restriction, denial of promotion, suspension, removal)

5. Has the personnel action described above been merely proposed or actually taken?
 Proposed
 Actually taken

Date of proposal:

Date of notification (of decision actually taken):

6. BRIEFLY describe the Agency's stated reason for taking the personnel action:

7. Have you taken any steps to formally challenge the Agency's action? (for example: replied to proposed discipline, filed a grievance, filed an MSPB appeal)
 Yes
 No

If Yes What step:

If Yes When taken:

If Yes Status:

8. Are you alleging discrimination?
 Yes
 No

9. What is the basis of the discrimination? (Check all that apply):
 Sex
 Race
 National Origin
 Color
 Marital Status
 Other
 Disability
 Age
 Sexual Orientation
 Religion
 Reprisal

If Other Please Describe:

10. BRIEFLY describe the events which you believe were discriminatory:

11. Have you contacted an EEO counselor within your Agency?
 Yes
 No

IF YES, date of contact:

12. If you have contacted an EEO counselor, have you filed a formal EEO complaint?
 Yes
 No

IF YES, date the complaint was filed:

13. If you have filed a formal complaint, have you received a Report of Investigation?
 Yes
 No

IF YES, date the Report was received:

14. Have you requested a hearing before an EEOC Administrative Judge?
 Yes
 No

IF YES, Date the request was filed:

What is the current status? (for example, have you received any orders from the judge? Has a hearing date been set?):

15. Have you begun any proceeding in any federal court related to the claim you are contacting us about?
 Yes
 No

IF YES, Date the request was filed:

What is the current status? (for example, have you received any orders from the judge? Has a hearing date been set?):

16. Are you facing any time deadlines related to ANY of the above claims?
 Yes
 No

IF YES, The date of the deadline is:

What is due by the deadline?:

17. Are you covered under a union contract?
 Yes
 No

IF YES, name and Local No. of union:

18. If you are covered under a union contract, have you requested the Union's assistance with your problem or has the Union intervened on your behalf?
 Yes
 No

IF YES, Date the union was contacted on this matter:

BRIEFLY describe the union's role:

19. Current employment status:
 Working
 On administrative leave
 Terminated as of: 
 Suspended as of: 
 Other: 

20. If an attorney cannot call you back today within normal business hours, what is the latest time an attorney can call you at home?