Form DHS Form 3090 DHS Form 3090 DHS Individual Complaint of Employment Discrimination

OMB No. 1610-0001 Expiration Date: 4/30/08
FOR OFFICIAL USE ONLY

DEPARTMENT OF HOMELAND SECURITY

DEPARTMENT CASE NUMBER

INDIVIDUAL COMPLAINT OF EMPLOYMENT
DISCRIMINATION

FILING DATE

(Use this form for original complaints and amendments.)

PART 1 COMPLAINANT IDENTIFICATION
1. NAME (Last, First, Middle Initial)

5. NAME AND ADDRESS OF ORGANIZATION WHERE YOU WORK (If a
Department of Homeland Security Employee)
Bureau or Component

2. TELEPHONE/FAX (Include Area Code)
Home

Fax

Office and Organizational Unit

Work

Fax

Street Address

3. HOME ADDRESS (You must notify the Department of any change of
address while complaint is pending, or your complaint may be
dismissed.)

City

State

Zip Code

6. EMPLOYMENT STATUS IN RELATION TO THIS COMPLAINT
Applicant
4. IF YOU ARE A CURRENT OR FORMER EMPLOYEE OF THE
FEDERAL GOVERNMENT, LIST YOUR RECENT TITLE,
SERIES, AND GRADE.

Probationary

Career/Career Conditional

Uniformed Service Member
Former Employee/Member

Title

Date Left Department
Retired

Series

Grade

Date of Retirement
Other (Specify)

7. I certify that all statements made in this complaint are true, complete, and correct to the best of my knowledge and

belief.
SIGNATURE OF COMPLAINANT OR ATTORNEY REPRESENTATIVE

DATE

PART II DESIGNATION OF REPRESENTATIVE
8. YOU MAY REPRESENT YOURSELF IN THIS COMPLAINT OR YOU MAY CHOOSE SOMEONE TO REPRESENT YOU. YOUR
REPRESENTATIVE DOES NOT HAVE TO BE AN ATTORNEY. YOU MAY CHANGE YOUR DESIGNATION OF A REPRESENTATIVE AT A
LATER DATE, BUT YOU MUST NOTIFY THE DEPARTMENT IMMEDIATELY IN WRITING OF ANY CHANGE, AND YOU MUST INCLUDE
THE SAME INFORMATION REQUESTED IN THIS PART.

"I hereby designate (Please Print Name)
to serve
as my representative during the course of this complaint. I understand that my representative is authorized to act
on my behalf."
Is the representative an attorney?
9. REPRESENTATIVE'S MAILING ADDRESS

YES

NO

10. REPRESENTATIVE'S EMPLOYER (If Federal Agency)

FIRM/ORGANIZATION

STREET ADDRESS

11. REPRESENTATIVE'S TELEPHONE/FAX (Include Area Code)
Telephone
Fax

CITY, STATE, & ZIP CODE

12a. COMPLAINANT'S SIGNATURE

DHS Form 3090-1 (9/04)

12b. DATE

Page 1 of 2

PART III ALLEGED DISCRIMINATORY ACTIONS
13. NAME OF PERSON OR DHS COMPONENT WHO TOOK THE
ACTION AT ISSUE.
FIRM/ORGANIZATION

14. ARE YOU WILLING TO PARTICIPATE IN MEDIATION OR OTHER
AVAILABLE TYPES OF ALTERNATIVE DISPUTE RESOLUTION
TO RESOLVE YOUR COMPLAINT?

STREET ADDRESS

YES

NO

CITY, STATE, & ZIP CODE

15. A.
B.
C.
D.

Describe the action taken against you that you believe was discriminatory.
Give the date when the action occurred, and the name of each person responsible for the action.
Describe how you were treated differently from other employees, applicants, or members for any of the reasons listed in Item 16.
Indicate what harm, if any, came to you in your work situation as a result of this action. (You may, but are not required to, attach
extra sheets.)
E. If the basis of your complaint is parental status, sexual orientation, or protected genetic information, use this form, but your complaint is
not statutorily based and will follow a separate, parallel process.

16. Mark below ONLY the bases you believe were relied on to take the actions described in Item 15.
RACE

AGE (Date of Birth)

COLOR

PHYSICAL OR MENTAL DISABILITY (Describe)
RETALIATION/REPRISAL (Dates of Prior EEO Activity)

RELIGION
NATIONAL ORIGIN (Specify)

SEXUAL ORIENTATION
PARENTAL STATUS

SEX (Specify)

PROTECTED GENETIC INFORMATION

17. WHAT REMEDIAL OR CORRECTIVE ACTION ARE YOU SEEKING TO RESOLVE THIS MATTER

18. ON THIS SAME MATTER, HAVE YOU FILED A GRIEVANCE OR APPEAL UNDER:

Negotiated grievance procedure

YES

NO

Agency grievance procedure

YES

NO

Merit Systems Protection Board appeal procedure

YES

NO

If you filed a grievance or appeal, provide date filed, case number, and present status.

PART IV CONTACT
EEO/EO Counseling is not required if you are requesting amendment of an existing, open complaint.
Complete items 24 and 25, even if you did not contact a counselor.
19. DATE YOU CONTACTED AN EEO COUNSELOR

20. NAME AND TELEPHONE NUMBER OF EEO COUNSELOR
Name

21. DID YOU DISCUSS ALL ACTIONS RAISED IN ITEM 15 WITH AN
EEO COUNSELOR? (If NO, explain on attached sheet)
YES

Phone

22. DATE YOU RECEIVED YOUR "NOTICE OF RIGHT TO FILE"

NO

23. IF YOU ARE REQUESTING AMENDMENT OF AN EXISTING, OPEN, FORMAL COMPLAINT (OR PROVIDING ADDITIONAL EVIDENCE),
INDICATE THE COMPLAINT CASE NUMBER OF THAT COMPLAINT.
24. DATE OF MOST RECENT DISCRIMINATORY EVENT

25. DATE YOU FIRST BECAME AWARE OF THE ALLEGED
DISCRIMINATION

Page 2 of 2

OMB No. 1610-0001 Expiration Date: 4/30/08
DEPARTMENT OF HOMELAND SECURITY
DHS FORM 3090-1, INDIVIDUAL COMPLAINT OF EMPLOYMENT
DISCRIMINATION FORM INSTRUCTIONS
(Read the following instructions carefully before you complete this form.)
(Please complete all items on the complaint form.)
GENERAL: This form should be used only if you, as an applicant for employment with the Department of Homeland
Security (DHS), or as a present or former Department of Homeland Security employee:
1)

believe you have been discriminated against because of your race, color, religion, sex, national origin,
age (40 years or older at the time of the event giving rise to your claim), physical or mental disability, or
in reprisal for opposition to activities protected by civil rights statutes, or participation in proceedings to
enforce those statutes; or

2)

believe you have been discriminated against because of your parental status, sexual orientation, or
protected genetic information. Your claim is not covered under statutory basis, but will be processed
under a parallel procedure, and

3)

have presented the matter for informal resolution to an Equal Employment Opportunity (EEO) Counselor
within 45 days of the event giving rise to your claim, or within 45 days of first becoming aware of the
alleged discrimination. If you are amending or providing additional evidence to an existing open complaint,
the form should be used, but EEO counseling is not required.

IMPORTANT NOTE: In certain situations, the information provided in Part III of the attached complaint form
may be used in lieu of an affidavit in the investigation of your complaint. Accordingly, the information you
provide in this part should be brief, clear, and complete.
WHEN TO FILE: In accordance with 29 CFR 1614.106, your formal complaint must be filed within 15 calendar days
of the date you received the “Notice of Right to File a Discrimination Complaint” from your EEO Counselor. You
must sign and date your complaint. If you are represented by an attorney, the attorney may sign the complaint on
your behalf.
These time limits may be extended:
1)

if you show that you were not notified of the time limits and were not otherwise aware of them, or

2)

if you were prevented by circumstances beyond your control from submitting the matter within the time
limits, or

3)

for other reasons considered sufficient by the Department.

REPRESENTATION: You may have a representative of your own choosing at all stages of the processing of your
complaint. However, your representative will be disqualified if such representation would conflict with the official
or collateral duties of the representative. 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.)
WHERE TO FILE: In accordance with 29 CFR 1614.106(c), your written complaint must be signed by you or your
attorney. The complaint should be filed with the EEO Director of the Department of Homeland Security component
where the alleged discrimination occurred. (Filing instructions are contained in the "Right to File" form, which was
provided by your Counselor.) Keep a copy of the completed complaint form for your records.

PRIVACY ACT STATEMENT
1.

FORM/TITLE/DATE: Department of Homeland Security (DHS) DHS Form 3090-1, Individual Complaint of
Employment Discrimination with the Department of Homeland Security.

2.

AUTHORITIY: 42 USC 2000e; 29 USC 633a; 5 USC 1303 and 1304;; 5 CFR 5.2 and 5.3; 29 CFR 1614.105
and 1614.107; and Executive Order 11478, as amended.

3.

PRINCIPAL PURPOSES: The purpose of this complaint form, whether recorded initially on the form or taken from
a letter from the Complainant, is to record the filing of a formal written complaint of employment discrimination with
the Department of Homeland Security on the grounds of race, color, religion, sex, national origin, age, physical or
mental disability, or retaliation. Information provided on this form will be used by DHS to determine whether the
complaint was timely filed and whether the allegations in the complaint are within the purview of 29 CFR Part 1614,
to provide a factual basis for investigation of the complaint, and to reach a decision on the complaint. It also
records an amendment or additional evidence to an open, pending complaint.

4.

ROUTINE USES: Other disclosures may be:

5.

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.

WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY, AND EFFECT OF NOT PROVIDING
INFORMATION: Formal complaints of employment discrimination must be in writing, signed by the Complainant
(or attorney representative), and must identify the parties and action or policy at issue. Failure to comply may
result in the Department of Homeland Security dismissing the complaint. It is not mandatory that this form be
used to provide the requested information.

OMB STATEMENT
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