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Appendix B: Pre-Complaint Election Form

Memorandum for: (Employee)

From: (EEO Counselor)

Subject: Pre-Complaint Election Form

On (date), you contacted the Equal Employment Opportunity office regarding an allegation of discrimination. Specifically you alleged that (issue/s and basis/es for complaint.) EEO-MD-110 Chapter 2, III (1) regulations require that I advise you about the EEO complaint process under 29 C.F.R. Part 1614.105, including the ADR/mediation program and the availability of mediation to you for resolving this case. Since your case is appropriate for mediation, the referenced EEO-MD-110 requires you to exercise an election option and decide whether to seek pre-complaint resolution through the ADR process or through the traditional EEO counseling process. As a Department of Commerce employee, you have been advised that you must seek resolution of these matters by electing EEO Counseling OR electing mediation. This Pre-Complaint Election Form must be returned to me, indicating your decision to elect EEO Counseling or to elect mediation, within five work days from the date of this memorandum.

If 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 permits sufficient time to arrange and conduct a mediation session within the time limits imposed by EEOC regulations.

If you elect to pursue mediation of your concerns, you are advised that:

  • Mediation is voluntary and will last no longer than forty-five (45) calendar days;
  • All discussions in mediation are confidential;
  • Statements made in settlement negotiations may not be used as evidence should you elect to file a formal complaint;
  • Requests for accommodation to facilitate the mediation session (e.g. auxiliary aids, interpreters, etc.) should be conveyed to the mediator at initial contact; and
  • You are entitled to a representative of your choice throughout the mediation process.

You will retain the right to file a formal complaint on those issues of discrimination 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 of Right to File (NRTF) at the termination of the counseling or mediation. Once you receive the NRTF, you will have 15 calendar days to file a formal complaint of discrimination on any unresolved issue(s).


  • I Elect EEO Counseling.
  • I Elect Mediation.


(Employee's signature and date)