Pre-Complaint Election Form
(date), you contacted the Equal Employment Opportunity office
allegation of discrimination. Specifically you alleged that
(issue/s and basis/es
for complaint.) EEO-MD-110 Chapter 2, III (1) regulations require
I advise you about the EEO complaint process under 29 C.F.R.
including the ADR/mediation program and the availability of
to you for resolving this case. Since your case is appropriate
the referenced EEO-MD-110 requires you to exercise an election
and decide whether to seek pre-complaint resolution through
the ADR process
or through the traditional EEO counseling process. As a Department
employee, you have been advised that you must seek resolution
matters by electing EEO Counseling OR electing mediation. This
Election Form must be returned to me, indicating your decision
EEO Counseling or to elect mediation, within five work days
from the date
of this memorandum.
you elect to pursue EEO Counseling, you are advised that you
still have the option
to elect mediation at a later time, provided the date of election
time to arrange and conduct a mediation session within the time
imposed by EEOC regulations.
you elect to pursue mediation of your concerns, you are advised
is voluntary and will last no longer than forty-five (45)
discussions in mediation are confidential;
made in settlement negotiations may not be used as evidence
should you elect to file a formal complaint;
for accommodation to facilitate the mediation session (e.g.
aids, interpreters, etc.) should be conveyed to the mediator
are entitled to a representative of your choice throughout
will retain the right to file a formal complaint on those issues
raised with me, the EEO Counselor, and not resolved during EEO
Counseling or mediation. If EEO Counseling or mediation is unsuccessful
in resolving any of your concerns, you will be issued a Notice
to File (NRTF) at the termination of the counseling or mediation.
receive the NRTF, you will have 15 calendar days to file a formal
of discrimination on any unresolved issue(s).
Elect EEO Counseling.
signature and date)