FCA Claim Form

• Section: Office of Congressional Workplace Rights (United States)

OCWR ADR Form 4 Page 1 Office of Congressional Workplace Rights The Fair Chance to Compete for Jobs Act (FCA) Claim Form Instructions on how to complete this claim form and how to obtain help are provided at the end of this form Section A: Information about you 1. Your full legal name: Last: ___________________ First: ___________________ Middle: ___________________ 2. Preferred mailing address: ____________________________________________________________________ City: ____________________ State: ______________ Zip code: _______________ 3. Preferred phone number: ___________________________ 4. Preferred email: ___________________________________ Section B: Information about your claim Please complete all the steps below: Step 1: Legislative branch employing office that this claim is filed against: ________________________________________________________________________ Step 2: Were you an applicant for employment with an employing office within the legislative branch? Yes [ ] No [ ] Step 3: Title of the position that you applied for: _______________________________________ • Was this position a law enforcement officer position? Yes [ ] No [ ] • Did this position require that you hold or maintain a security clearance? Yes [ ] No [ ] I don’t know [ ] Step 4: Date you applied: _______________________________ Step 5: Did the employing office request that you disclose criminal history record information? Yes [ ] No [ ] Step 6: Date of the employing office’s request for criminal history record information: _________________________________________ Office of Congressional Workplace Rights John Adams Building, 110 Second Street SE, Room LA-200 | Washington, DC 20540-1999 | (202) 724-9250 (O) | ocwr.gov Revised June 2024 OCWR ADR Form 4 Step 7: What was the nature of the request for criminal history record information? [ ] In writing (such as a request on an employment application) [ ] Orally (such as an oral request made during an employment interview) Step 8: Name and title of the employee(s) who requested this information (if known): ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Step 9: Did the employing office extend a conditional offer of employment to you? (A conditional offer of employment is an offer of employment that is conditioned only upon your further response...