VA4939
Complaint of Employment Discrimination
VA Form VA4939 is the U.S. Department of Veterans Affairs Complaint of Employment Discrimination. Its instructions say it can be used by VA employees, former employees and applicants for employment who file a formal Equal Employment Opportunity (EEO) complaint of discrimination under the EEOC regulations at 29 C.F.R. §1614. It is an employment form, not a Veterans benefits application.
The front page identifies the complainant and the VA facility where the discrimination occurred, then asks for the bases and claims of the complaint, the dates, the remedies sought and details about a representative, EEO counseling, union grievances and Merit Systems Protection Board appeals. The reverse side holds the instructions, the Privacy Act statement and the respondent burden statement.
The form is two pages and prints OMB No. 2900-0716. The instructions say the Office of Resolution Management, Diversity and Inclusion (ORMDI) uses the information to decide whether the complaint is acceptable for investigation. You can fill out the PDF free in your browser on this page and download the result without an account.
Name, email address, mailing address, work and primary telephone numbers, whether the complainant is a VA employee, an applicant or a former employee, job title, series and grade, service or section, and the name and address of the VA facility where the discrimination occurred.
The bases the form lists are race, color, religion, sex (including sexual orientation and gender identity), national origin, age (with date of birth), disability, genetic information (including family medical history) and reprisal. The instructions ask that a reprisal basis state the prior EEO activity.
The employment related claims, such as personnel actions, incidents or events, the date of occurrence with the most recent date, and the remedies sought. The form says not to include information that violates the Privacy Act or HIPAA, such as patient medical records or other employees' personal records.
Whether there is a representative and whether that person is an attorney, with their name, address, phone and email, then whether an EEO Counselor was contacted, the counselor's name and the date of initial contact with ORM.
Item 14 is for explaining a late counseling contact or a late complaint. Items 15 to 17 ask whether a union grievance, a Merit Systems Protection Board appeal or the same complaint was filed elsewhere, with the claims and dates.
The complainant's signature, which the form says is signed in ink and not printed, and the date.
The form says to read the instructions on the reverse side carefully before completing the front, and to complete all items.
The instructions say the claims in item 9 are limited to those discussed with an EEO Counselor, or like or related claims. For a claim not discussed with a counselor, they say to contact the ORMDI Regional EEO Officer immediately.
The instructions stress being precise about the dates of all actions or events in the complaint. Item 10 asks for the date of occurrence, including the most recent date.
The instructions say the formal complaint is filed within 15 calendar days of receiving the NRTF. Item 14 is where a complainant explains counseling sought more than 45 calendar days after the event or a complaint filed after the 15 days.
Sign item 18 in ink and date item 19, then file the complaint with the ORMDI District Office named in the NRTF, following the cover letter attached to the NRTF.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
The instructions say the complaint should be filed with the ORMDI District Office identified in the NRTF. Filing instructions are in the cover letter attached to the NRTF.
The instructions say a copy can be submitted by mail, in person, electronically by email or by facsimile.
The instructions say to tell the ORMDI District Office of a new address right away and to claim all certified and express mail about the complaint. They say failing to do either may lead to dismissal of the complaint.
The burden statement lists VA Clearance Officer (005R1B), 810 Vermont Avenue, Washington, DC 20420 for comments only. The form says not to send the form or a complaint of employment discrimination to that address.
The JUL 2020 edition supersedes VA Form 4939, MAR 2017, which the form says should not be used. It carries OMB No. 2900-0716 and a respondent burden of 30 minutes. VA's form page lists a revision date of March 2017.
The instructions name the people who file the complaint and the offices involved.
No tool matches that search.
The instructions say VA employees, former employees and applicants for employment who file a formal Equal Employment Opportunity complaint of discrimination can use it.
No. It is the form for a formal EEO complaint of employment discrimination at VA, under the EEOC regulations at 29 C.F.R. §1614.
The instructions say the formal complaint is filed within 15 calendar days of the date the Notice of Right to File a Discrimination Complaint was received from the EEO Counselor. A later filing is explained in item 14. The instructions say these limits may be extended under certain circumstances but will not be waived.
The instructions say the EEO Counselor can help fill out the form and answer questions about it. A complainant may also have a representative of their own choosing at all stages.
The instructions say the representative need not be an attorney, but only an attorney representative may sign the complaint on the complainant's behalf.
The form says not to include information that violates the Privacy Act of 1974 and HIPAA, giving patient medical records and personal records of other VA employees as examples.
To the ORMDI District Office identified in the NRTF, by mail, in person, by email or by fax. The Washington, DC address in the burden statement is for comments only.
