EEO Class Complaint Against the U.S. Department of Energy

 

I, the undersigned, hereby state that I am a black or Afro- American who is, or was, an employee or applicant for a  job with the U.S. Department of Energy (DOE) and claim discrimination or retaliation against me by DOE on the basis of the following checked items, corresponding to num­bered items in the Class Complaint List in the Class Action Complaint of Roderick Ott, class agent, against the U.S. Department of Energy:

 

G   1

G   7

G 13

G 19

G 25

G 31

G 37

G 43

G 49

G 55

G 61

G 67

G 73

G   2

G   8

G 14

G 20

G 26

G 32

G 38

G 44

G 50

G 56

G 62

G 68

G 74

G   3

G   9

G 15

G 21

G 27

G 33

G 39

G 45

G 51

G 57

G 63

G 69

G 75

G   4

G 10

G 16

G 22

G 28

G 34

G 40

G 46

G 52

G 58

G 64

G 70

G 76

G   5

G 11

G 17

G 23

G 29

G 35

G 41

G 47

G 53

G 59

G 65

G 71

G 77

G   6

G 12

G 18

G 24

G 30

G 36

G 42

G 48

G 54

G 60

G 66

G 72

G 78

 

Additionally, I add the following specific claims of discrimination or retaliation against me (write below, or reference attached sheets, if any):

 

 

 

 

 

 

 

 

 

Earliest date on which discrimination or retaliation occurred:

 

Most recent date on which discrimination or retaliation occurred:

 

Name:

Gender (check): G male G female

DOE Organization:

DOE Location:

Phone # to call:

This # is (check): G work G home G other

Home Address - Street

P.O. Box

City

State

Zip

 

I am supplying this information on a confidential basis, for use by the class agent and the lawyers representing the class in this complaint.  I am providing my name, address, other identifying information, and signature with the understanding that this information will not be divulged to DOE or anyone other than the class agent and lawyers represen­ting the class without my explicit signed release.  I do not authorize release of informa­tion identifying me as a participant in this class action at this time.  I do authorize use of information about my complaint without me being personally identified.

 

 

Signature:                                                                    Date:

 

FAX COMPLETED FORM TO: 800-690-1522 NOT LATER THAN OCTOBER 20, 1999

 

Mail to: Roderick Ott, 790 N. Cedar Bluff Rd., Apt. 315, Knoxville, TN 37923