SSA CLASS ADVISORY BOARD

INTAKE FORM

Date _____/_____/_____

Last Name First Name Middle Initial

Social Security Number

Address

Phone hm ( ) wk ( ) cell ( )

Email

Position and Component

First Level Supervisor (Name and Title)

Second Level Supervisor (Name and Title)

Does your problem involve? ______ Individual Development Plan ______ Needing an Advocate

____ Promotion _ ___ Awards Training Discipline _ ___ Other

Description of the problem:

Provide this form to one of the CAB Members: Myron "Moe" Bundy, Donald Covington, Michael A. Dorsey, Harry M. Dunbar, Rudolph A. Greene, Sr., Robert L. Jackson, Norwood Johnson, Clifton J. Lawrence, Wes Turpin.

IMPORTANT: If you have a concern that involves discrimination or a union grievance you must still contact the appropriate office in order to pursue those claims. For instance, if you have an EEO complaint, you must still contact an EEOC counselor within 45 days of the discriminatory incident. For further information on these issues, please contact Cathy Harris at Kator, Parks, Weiser, PLLC, 202-898-4800.