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The PS Form 2564 A serves as a critical tool for individuals seeking assistance related to workplace discrimination within the U.S. Postal Service. This form is designed to collect essential information that helps facilitate pre-complaint counseling for employees who have faced discriminatory actions. Notably, it incorporates sections that require the requester to provide personal details, such as their name, employment status, and contact information. It also prompts individuals to specify the nature of the alleged discrimination, which may include aspects like race, sex, or disability, among others. A significant feature of this form is its emphasis on detailing the incidents or actions that prompted the need for EEO counseling, along with comparisons to how individuals perceive they were treated differently than their peers. Furthermore, the form guides users through identifying responsible officials and seeking specific resolutions to their grievances. By outlining the procedural steps, including deadlines for submission and guidelines for representation, the PS Form 2564 A aims to create a structured approach to resolving discrimination issues within the Postal Service, ensuring that employees have a clear path forward in addressing their concerns.

Ps 2564 A Example

U.S. Postal Service

Information for Pre-Complaint Counseling

Certified Mail No.

Date Mail

or Hand Delivered On

 

 

 

 

 

 

 

 

By (Initials)

Case No.

 

 

 

 

 

 

On _________________________________, you requested an appointment with a Dispute Resolution Specialist.

Month, Day, Year

Important: Please Read. You should complete this form and return it to the EEO office within 10 calendar days of receipt. This the only notification that you will receive regarding the necessity for you to complete this form.

A. Requester Information

Name (Last, First, MI)

Social Security No.

Home Telephone No.

()

Your Mailing Address

Name of Postal Facility Where You Work

Office Telephone No.

()

Address of Postal Facility

 

 

 

Email Address *

 

 

 

 

 

 

 

 

 

 

 

Employment Status (Check One)

 

 

Position Title

Grade Level

 

Applicant

Casual

TE

Career

 

 

 

 

 

 

 

 

 

 

Pay Location

Tour

Duty Hours

 

Off Days (If Tour I, Show Nights Off)

Time in Current Position

 

 

 

 

 

 

____ Years

____ Months

 

 

 

 

 

 

Your Supervisor’s Name

 

 

Supervisor’s Title

Supervisor’s Telephone No.

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

*Providing this information will authorize the U.S. Postal Service to send you important documents electronically.

B. Discrimination Factors

Prohibited discrimination includes actions taken based on your Race, Color, Religion, Sex, Age (40+), National Origin, Physical and/or Mental

Disability, or in Retaliation (actions based on your participation in prior EEO activity). These categories are referred to on this form as factors.

What Factor(s) of Discrimination Are You Alleging? (Please be specific, i.e., Race - African American, Sex - Female.)

For Retaliation Allegations Only: If you are alleging retaliation discrimination, provide the date(s) and specifics of the EEO activity which you feel caused you to be retaliated against.

1.

On ___________________________, I engaged in EEO activity.

Case No.: __________________________.

 

Month, Day, Year

 

2.

On ___________________________, I engaged in EEO activity.

Case No.: __________________________.

 

Month, Day, Year

 

C. Description of Incident/Activity

Please use the space below to briefly describe the incident or action that prompted you to seek EEO counseling at this time.

On _____________________________________, 20____,

 

Month, Day

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PS Form 2564-A, March 2001 (Page 1 of 3)

D. Comparisons

Explain why, based on the factors you cited in Section B, you believe that you were treated differently than other employees or applicants in similar situations.

1.

(Name of Employee)

Factor(s) that describe the employee, i.e., sex (male), National Origin (Hispanic)

was treated differently than I when:

2.

(Name of Employee)

Factor(s) that describe the employee, i.e., sex (male), National Origin (Hispanic)

was treated differently than I when:

3.

(Name of Employee)

Factor(s) that describe the employee, i.e., sex (male), National Origin (Hispanic)

was treated differently than I when:

E. Official(s) Responsible for Action(s)

List the name(s) of the official(s) who took the action which prompted you to seek counseling at this time.

1a. Name

b. Title

c. Office

d. Grade Level

2a. Name

b. Title

c. Office

d. Grade Level

Retaliation Allegations Only: Was/were the official(s) listed in Section E above aware of your prior EEO activity?

Yes

No

If yes, explain how the official(s) became aware:

 

 

 

 

 

 

F. Resolution

What are you seeking as a resolution to your pre-complaint?

G. Grievance/MSPB Appeal

On the incident that prompted you to seek EEO counseling, have you:

1.

Filed a grievance on the issue?

No

Yes

If yes,

 

 

 

 

 

 

 

(Date)

 

(Current Step)

2.

Filed an MSPB appeal on this issue?

No

Yes

If yes,

 

 

 

 

 

 

 

(Date Appeal Filed)

 

 

PS Form 2564-A, March 2001 (Page 2 of 3)

H. Anonymity

You have the right to remain anonymous during the pre-complaint process.

Do you desire anonymity?

No

Yes

I. Representation

You have the right to retain representation of your choice. (Check One)

I waive the right to representation at this time.

I authorize the person listed below to represent me.

Name of Representative

Organization

Representative’s Title

Telephone No.

Email Address *

()

Mailing Address (Street or P.O. Box, City, State and ZIP + 4)

*Providing this information will authorize the U.S. Postal Service to send your representative important documents electronically.

J. Documentation

Please attach any documentation you wish to submit to support your allegation(s) Include a copy of any written action(s) that caused you to seek counseling at this time.

Note: If you are alleging mental and/or physical disability, it is important for you to submit medical documentation of your disability during the pre- complaint process.

K. Privacy Act Statement

Privacy Act Notice. The collection of this information is authorized by the Equal Employment Opportunity Act of 1972, 42 U.S.C. § 2000e-16; the Age Discrimination in Employment Act of 1967, as amended, 29 U.S.C. § 633a; the Rehabilitation Act of 1973, as amended, 29 U.S.C. § 794a; and Executive Order 11478, as amended. This information will be used to adjudicate complaints of alleged discrimination and to evaluate the effectiveness of the EEO program. As a routine use, this information may be disclosed to an appropriate government agency, domestic or foreign, for law enforcement purposes; where pertinent, in a legal proceeding to which the USPS is a party or has an interest; to a government agency in order to obtain information relevant to a USPS decision concerning employment, security clearances, contracts, licenses, grants, permits or other benefits; to a government agency upon its request when relevant to its decision concerning employment, security clearances, security or suitability investigations, contracts, licenses,

grants or other benefits; to a congressional office at your request; to an expert, consultant, or other person under contract with the USPS to fulfill an agency function; to the Federal Records Center for storage; to the Office of Management and Budget for review of private relief legislation; to an independent certified public accountant during an official audit of USPS finances; to an investigator, administrative judge or complaints examiner appointed by the Equal Employment Opportunity Commission for investigation of a formal EEO complaint under 29 CFR 1614; to the Merit Systems Protection Board or Office of Special Counsel for proceedings or investigations involving personnel practices and other matters within their jurisdiction; and to a labor organization as required by the National Labor Relations Act. Under the Privacy Act provision, the information requested is voluntary for the complainant, and for Postal Service employees and other witnesses.

L. Authorization

I am aware that the claim(s) contained herein shall by-pass the pre-complaint process if like or related to a formal complaint that I have already filed, or if the claim(s) constitutes a spin-off complaint. (A spin-off complaint contests the manner in which a previously filed complaint is being processed.) In completing this PS Form 2564-A, Information for Pre-Complaint Counseling, I recognize that the Manager, Dispute Resolution, will review the claim(s) contained herein and determine how they shall be processed. I will be notified, in writing, if the Manager determines that my claim(s) shall be processed as amendments or appendages to a formal complaint that I have already filed.

Please Print Your Name Here

Your Signature

Date Signed

Please Return This Form to:

EEO Processing

P O Box 1017

Dallas, Texas 75221-1017

PS Form 2564-A, March 2001 (Page 3 of 3)

Get Ps 2564 A PDF Form

Form Characteristics

Fact Name Description
Form Purpose The PS Form 2564 A is for requesting pre-complaint counseling with the U.S. Postal Service regarding allegations of discrimination.
Submission Deadline Individuals must complete and return this form to the EEO office within 10 calendar days of receiving it.
EEO Activity Dates Users must provide specific dates when they engaged in EEO activities that they believe led to discrimination or retaliation.
Discrimination Factors Prohibited discrimination includes actions based on race, color, religion, sex, national origin, and several other protected categories.
Privacy Act Compliance The information collected by this form is authorized under various laws, including the Equal Employment Opportunity Act of 1972.
Right to Anonymity Complainants have the right to remain anonymous during the pre-complaint process, should they choose to do so.
Representation Rights Individuals can choose to waive their right to representation or authorize someone else to represent them in the process.
Document Submission Complainants are encouraged to attach documentation supporting their allegations, including medical records if applicable.

Guidelines on Utilizing Ps 2564 A

Completing the PS Form 2564 A is essential for initiating the pre-complaint counseling process. The form must be returned to the EEO office within 10 calendar days of receipt. Ensure all sections are filled out completely and accurately to facilitate timely processing.

  1. Begin by entering the Certified Mail No. and the Date you are filling out the form.
  2. Indicate whether the form was Mail or Hand Delivered and provide the initials of the person delivering it.
  3. Fill in the Case No. if applicable or leave it blank if not.
  4. In Section A, provide your Name (Last, First, MI), Social Security No., Home Telephone No., and your Mailing Address.
  5. Input the Name of Postal Facility Where You Work, its Office Telephone No., and the Email Address.
  6. Select your Employment Status and complete the relevant employment details, including Position Title, Grade Level, Pay Location, Tour, Duty Hours, and Off Days.
  7. Provide the details of your Supervisor including their Name, Title, and Telephone No..
  8. Proceed to Section B and specify the Factor(s) of Discrimination you are alleging. Give specifics, such as Race or Sex.
  9. If applicable, for Retaliation Allegations, document the dates of your EEO activity and corresponding Case No..
  10. In Section C, describe the Incident/Activity that led you to seek EEO counseling.
  11. Fill out Section D with comparisons to other employees, detailing treated differently citing their Name and relevant Factors.
  12. In Section E, list the Official(s) Responsible for Action(s), including their Name, Title, Office, and Grade Level.
  13. Answer whether the official(s) were aware of your prior EEO activity.
  14. Section F requests what you are seeking as a Resolution.
  15. In Section G, indicate if you have filed a grievance or an MSPB appeal, stating dates as necessary.
  16. Decide whether you wish to remain Anonymous during the process and check the appropriate box.
  17. Discuss your right to Representation and whether you waive this right or authorize a representative.
  18. Attach any Documentation that supports your allegations in Section J.
  19. Complete the Privacy Act Statement to understand how your information will be used.
  20. Lastly, print your name, provide your signature, and indicate the Date Signed.
  21. Submit the completed form to the designated office address provided at the end of the form.

What You Should Know About This Form

What is the PS Form 2564 A?

The PS Form 2564 A is a document used by employees of the U.S. Postal Service to initiate the pre-complaint counseling process regarding alleged discrimination. It serves as a formal notification of a request for an appointment with a Dispute Resolution Specialist and helps gather the necessary information about the alleged discrimination, including details about the complainant, the alleged discriminatory actions, and any desired resolutions.

Who should fill out the PS Form 2564 A?

This form should be filled out by any U.S. Postal Service employee or applicant who believes they have experienced discrimination based on race, color, religion, sex, age, national origin, physical or mental disability, or retaliation. Completing this form is a necessary step for those seeking to address their grievances formally.

Where should I send the completed PS Form 2564 A?

Once you have filled out the form, it should be mailed to the EEO Processing center at P.O. Box 1017, Dallas, Texas 75221-1017. It’s essential to ensure that it is sent within the specified timeframe to facilitate timely processing.

What happens after I submit the PS Form 2564 A?

After you submit the form, the Manager of Dispute Resolution will review your claims. You will receive notification in writing regarding how your claim will be processed, including whether it will proceed as an amendment to a formal complaint if applicable. This communication will provide clarity on the next steps in your case.

What is the significance of the discrimination factors section?

The discrimination factors section is critical because it specifies the categories under which you believe you have faced discrimination. By outlining these factors clearly, it helps the dispute resolution process to focus on the relevant issues and understand the context of your complaint, which is necessary for effective resolution.

Is there a deadline for submitting this form?

Yes, it is crucial to complete and submit the PS Form 2564 A within 10 calendar days of receiving it. This deadline ensures the U.S. Postal Service can process your request for counseling correctly and within a reasonable timeframe.

Can I remain anonymous during the process?

Yes, an employee has the right to request anonymity during the pre-complaint counseling process. If you choose to maintain your anonymity, please indicate this preference on the form. However, it is worth noting that remaining anonymous may impact the investigation of your claims.

What should I include as supporting documentation?

When submitting the PS Form 2564 A, it is advisable to include any documentation that supports your allegations. This could consist of written actions that prompted your grievance, emails, and, if applicable, medical documentation related to any claimed disabilities. Such evidence helps substantiate your claims and provides a clearer picture of your situation.

Can I have someone represent me in this process?

Yes, you have the right to select a representative of your choice to assist you during the pre-complaint counseling process. If you decide to have representation, ensure that you provide the necessary details regarding your representative on the form, including their contact information and the organization they represent.

What if I have already filed a formal complaint?

If you have already filed a formal complaint that is related to the claims in your PS Form 2564 A, those claims may bypass the pre-complaint process. It’s essential to indicate this clearly on the form to avoid duplication and ensure the appropriate handling of your case.

Common mistakes

Filling out the PS 2564 A form correctly is crucial for effectively communicating your concerns regarding discrimination. However, several common mistakes can hinder this process. One frequent error is failing to fill out the Requester Information section accurately. This section gathers essential details such as your name, Social Security number, and contact information. Incomplete or incorrect information can lead to delays in your case being processed.

Another mistake is neglecting to specify the Factors of Discrimination. This section asks you to identify the discrimination factors you believe impacted your situation. Be precise in your descriptions, such as identifying your race or gender. Vague responses can weaken your claim and make it harder for the resolution team to understand your situation.

People often overlook the importance of the Description of Incident/Activity section. Without providing enough detail about the incident that prompted your complaint, your case may lack the necessary context. Describe the event clearly, including dates and specifics. This narrative provides a foundation for your claims and helps the review team assess your situation accurately.

Additionally, some individuals fail to discuss Comparisons adequately. This part of the form allows you to illustrate how you have been treated differently compared to others in similar roles. Listing comparisons and providing details can significantly bolster your case. Many make the mistake of leaving this section blank or under-explained, missing an opportunity to strengthen their allegations.

Being imprecise in the Resolution section is another misstep. Clearly stating what you hope to achieve can guide the resolution team in addressing your concerns effectively. Without a well-defined resolution request, your claim may not be directed toward an appropriate solution.

Another common issue arises in the Documentation section. Attaching necessary evidence to support your claims is essential. People sometimes forget to include relevant documents, which can undermine the strength of their case. Always double-check that you’ve attached any documentation necessary to substantiate your allegations.

Finally, a lack of attention to the Privacy Act Statement can lead to confusion regarding your rights. Be sure to understand how your information will be used. Ignoring this important section can result in incorrect assumptions about confidentiality and could impact the trust built with the EEO office during the complaint process.

Documents used along the form

When you are navigating the pre-complaint counseling process with the U.S. Postal Service, understanding the various forms and documents involved can be crucial. Each of these documents serves a distinct purpose, often working in conjunction with the PS Form 2564-A. Below is a list of frequently used forms and documents you may encounter along the way. Each description aims to clarify their significance in the process.

  • EEO Complaint Form: This is the primary document used to formally lodge a complaint regarding employment discrimination. It outlines the nature of the complaint, details of the alleged incidents, and the individuals involved.
  • Grievance Form: Should you choose to address your concerns through a grievance process, this form allows you to detail your issue and seek resolution within your workplace instead of an external EEO complaint.
  • MSPB Appeal Form: If your case involves adverse actions like suspension or removal, this form is used to appeal decisions made by the Merit Systems Protection Board concerning those actions.
  • Representation Authorization Form: This document gives authority to another individual to represent you during the EEO process, allowing them to communicate on your behalf.
  • Documentation Checklist: A helpful list that outlines what types of evidence you should gather to support your allegations, such as emails, memos, or workplace policies.
  • Privacy Act Statement: This statement explains your rights regarding the privacy of the information you provide during the EEO process, ensuring you understand how your data will be used.
  • Medical Documentation: If you are claiming discrimination based on a disability, it's crucial to provide valid medical records to substantiate your claims and support your case.
  • Incident Report Form: This form allows you to outline specific incidents of alleged discrimination or harassment as they occur, serving as a factual account of events relevant to your complaint.
  • Follow-Up Correspondence: Any letters or emails from the EEO office or your employer, detailing the status of your complaint or any required actions from you, serve as vital documentation in the process.

Being familiar with these forms can ease some of the uncertainty surrounding the resolution process. It’s important to approach this journey with careful preparation and support, ensuring that your voice is heard and respected throughout.

Similar forms

  • EEO Complaint Form: Similar to PS Form 2564-A, the EEO Complaint Form collects information about allegations of discrimination at work. It requires details about the incident, the parties involved, and the desired resolution, creating a comprehensive overview to initiate an investigation.
  • Grievance Form: Like the PS Form 2564-A, a Grievance Form allows employees to formally report issues at work. It captures specific complaints but focuses more on workplace policies and procedures rather than discrimination based on personal characteristics.
  • Request for Counseling Form: This form serves a similar purpose by documenting the request for assistance in resolving workplace disputes. It equally emphasizes the need for timely submission, ensuring that employees understand the importance of addressing their concerns promptly.
  • Workplace Harassment Reporting Form: Similar to the PS Form 2564-A, this document helps identify and report claims of harassment based on various factors such as race or gender, creating a structured method for addressing serious workplace issues.
  • Disability Disclosure Form: Like PS Form 2564-A, this form enables employees to disclose any disabilities that may affect their work situation. It emphasizes the need for proper documentation and a clear understanding of the employee's rights and protections under the law.

Dos and Don'ts

Filling out the PS 2564 A form can be an important step in addressing your concerns. Here are some things to do and avoid.

  • Do complete the form within 10 calendar days of receiving it.
  • Do provide your personal information accurately, including your contact details.
  • Do clearly specify the factors of discrimination you are alleging.
  • Do attach any relevant documentation that supports your claims.
  • Do describe the incident briefly and provide as many specifics as possible.
  • Don't leave any sections of the form blank unless specified.
  • Don't include irrelevant information or unsubstantiated claims.

Misconceptions

Misconception 1: The PS 2564 A form is only for employees currently facing discrimination.

This form is not restricted to those actively experiencing discrimination. It is designed for anyone who believes they have been subjected to prohibited discrimination in the workplace, regardless of their current situation. This includes individuals who may have faced discrimination in the past but are only now seeking to address it.

Misconception 2: Completing the PS 2564 A form guarantees a formal complaint will be filed.

Submission of this form initiates the pre-complaint process, but it does not automatically lead to a formal complaint. Upon review, the Manager, Dispute Resolution, will assess the information provided and decide on the next steps. It’s essential to understand that additional action may be required to escalate the matter.

Misconception 3: Individuals must have legal representation to complete the PS 2564 A form.

While individuals have the right to seek representation, it is not a requirement. The form allows users to waive their right to representation at any stage if they choose to do so. Understanding the process and articulating one's concerns is possible without legal assistance.

Misconception 4: Anonymity is not an option when completing the PS 2564 A form.

This form explicitly states that individuals have the right to remain anonymous during the pre-complaint process. Anonymity offers a layer of protection and can encourage individuals to come forward without fear of retaliation or further discrimination.

Key takeaways

The PS Form 2564 A is an important document for those seeking pre-complaint counseling with the U.S. Postal Service. Understanding how to fill it out and use it effectively can make the process smoother. Here are some key takeaways:

  • Timeliness Matters: Complete the form and return it to the EEO office within 10 calendar days of receipt to ensure your request is processed without delays.
  • Provide Accurate Information: Fill in your personal and employment information accurately. This includes your name, Social Security number, and postal facility details.
  • Specify Allegations: Clearly state the factors of discrimination you believe apply to your situation. Be specific about the nature of discrimination, whether it be based on race, sex, or disability.
  • Document Incidents: Use the space provided to describe the incidents that led to your counseling request. Include dates and specifics to give context to your claims.
  • Identify Comparisons: Address why you believe you were treated differently than others in similar situations. Provide names and relevant factors regarding those comparisons.
  • Consider Anonymity: You have the option to remain anonymous during the pre-complaint process. Decide if this is important for you and indicate accordingly.
  • Attach Supporting Documentation: If you have documentation that supports your case, include it with your form. This might include emails, memos, or medical records if applicable.

Being thorough and precise in your responses will help ensure a better outcome during the counseling process. Take your time to carefully fill out the PS Form 2564 A.

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