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Appendix C: Formal Complaint Mediation Election Form

Memorandum for: (Complainant)

From: Department EEO ADR Manager

Subject: Formal Complaint Mediation Election Form

On (date), you submitted to the Office of Civil Rights, Department of Commerce, a Complaint of Employment Discrimination. Specifically, you alleged that (issue/s and basis/es for complaint.)

On (date), the Office of Civil Rights issued you a Notice of Acceptance for Investigation, which cites the accepted claim for investigation, and informs you of your rights and responsibilities, including the conditions under which you would be eligible to elect Alternative Dispute Resolution (ADR), through mediation. The determination is made that your case is appropriate for mediation.

If you elect mediation of your complaint, please be advised that:

  • All discussions in mediation are confidential;
  • Statements made in settlement negotiations may not be used as evidence;
  • Requests for accommodation to facilitate the mediation session (e.g. auxiliary aids, interpreters, etc.) should be conveyed to me as soon as possible;
  • You are entitled to a representative of your choice throughout the mediation process; and
  • Even if you elect mediation, OCR will proceed with investigation of your complaint, to ensure that a complete, impartial record is compiled within the time frame dictated by 29 C.F. R., Part 1614.018.


I Elect Mediation.


(Employee's signature and date)