NIH - OEODM - Complaints Processing - Designation of Representative

Designation of Representative

Instructions:

You have the right, at any stage in the presentation of a complaint, to be represented by an individual of your choice, unless your choice results in a conflict of interest for the person chosen. The designated representative may accompany, represent, advise, and assist you in the preparation and presentation of your complaint.

When you designate a representative, you give consent to the Office of Equal Opportunity and Diversity Management (OEODM) to disclose all information concerning the complaint to the person designated. Failure to complete and return this form or a similar statement will preclude any representative from participating in the case while it is pending before the OEODM.

According to 29 C.F.R.1614.605 (d), after the OEODM has received written notice of the name, address, and telephone number of your representative, all official correspondence shall be served to your representative with copies to you.

If your representative is an attorney, all official correspondence will be served to your attorney, and not to you. Time frames for the Agency’s receipt of materials shall be computed from the time your attorney receives documents.

You are responsible for notifying the OEODM in writing of such representation, or any change in representation (i.e., name, address, and telephone number).

Please complete this form and submit it to the OEODM in order for your designation of representative to be valid.

Designation of Representative Notice

I understand the above instructions and hereby designate the individual named below to represent me in connection with my complaint.

Effective Date:	_________________
Name of Representative:	________________________________________________
Representative's Address:	________________________________________________
City/State/ Zip Code:	________________________________________________
Telephone Number:	___________________________
Fax Number:	___________________________

Is your representative an attorney? Yes ( ) No ( )

I understand that I, or any other individual that I so delegate, may cancel this notice, and that I am responsible for notifying the OEODM in writing in the event of a cancellation.

My Name is:	________________________________________________
Contact Phone:	___________________________
Signature:	________________________________________________

Return this form via fax 301.402.0994 or by mail to:

NIH Office of Equal Opportunity and Diversity Management
Building 2, Third Floor Suite, MSC-0245
Bethesda, MD 20982