This form is affected by the Privacy Act of 1974; Public Law 93-579. Read the Privacy Act Statement before completing this form.
Please answer the following questions, telling us briefly why you have been discriminated against in employment. An officer of the Equal Employment/Fair Housing Office will talk with you after you complete this form.
Upon submission of this form, an investigator from the Equal Employment/Fair Housing office will contact you within three days to perfect your charge.
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