The U.S. Equal Employment Opportunity Commission

Appendix G EEO-MD-110

EEO COUNSELOR'S REPORT
29 C.F.R. 1614.105

I.   REQUIRED ELEMENTS

     A.   AGGRIEVED PERSON

          Name:

          Job Title/Series/Grade:________________________________________________

          Place of Employment:__________________________________________________

          Work Phone No:______________ Home Phone No:________________________

          Home Address: ______________________________________________________
                    ________________________________________________________
                    ________________________________________________________

     B.   CHRONOLOGY OF EEO COUNSELING

          Date of Initial Contact:

          Date of Initial Interview:______________________________________________ 
                                                                                          
          Date of Alleged Discriminatory Event:___________________________________

          45th Day After Event:_________________________________________________

          Reason for delayed contact beyond 45 days, if applicable:
          ____________________________________________________________________
          ____________________________________________________________________
          ____________________________________________________________________

          Date Counseling Report Requested:_____________________________________

          Date Counseling Report Submitted:_____________________________________

     C.   BASIS(ES) FOR ALLEGED DISCRIMINATION

          1) [   ] Race (Specify)_______________________________________
          2) [   ] Color (Specify)______________________________________
          3) [   ] National Origin (Specify)______________________________
          4) [   ] Sex (Specify)________________________________________
          5) [   ] Age (Date of Birth)___________________________________
          6) [   ] Mental Disability (Specify)____________________________
          7) [   ] Physical Disability (Specify)___________________________
          8) [   ] Religion (Specify)____________________________________
          9) [   ] Reprisal (Identify earlier event and/or opposed
                 practice, give date)__________________________________

     D.   PRECISE DESCRIPTION OF THE ISSUE(S) COUNSELED



     E.   REMEDY REQUESTED



     F.   EEO COUNSELOR'S CHECKLIST - THE COUNSELOR ADVISED THE
          AGGRIEVED PERSON IN WRITING OF THE RIGHTS AND 
          RESPONSIBILITIES CONTAINED IN THE EEO COUNSELOR CHECKLIST.



II.  SUMMARY OF INFORMAL RESOLUTION ATTEMPTS

     A.   IF THE COUNSELOR ATTEMPTED RESOLUTION

          1.   Personal Contacts



          2.   Documents Reviewed




          3.   Summary of Informal Resolution Attempt



     B.   IF AGGRIEVED OPTED FOR ADR, COUNSELOR'S STATEMENT THAT
          THE ADR PROCESS WAS FULLY EXPLAINED TO THE AGGRIEVED
          INDIVIDUAL/SUMMARY OF INFORMATION GIVEN TO THE AGGRIEVED
          INDIVIDUAL AND THE AGENCY BY THE COUNSELOR






_____________________________       __________________________
     Name of EEO Counselor              Telephone Number


_____________________________       ___________________________
     Signature of Counselor             Office Address


_____________________________
          Date                    

This page was last modified on November 8, 1999.

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