FCA Claim Form

• Legal Form Number: Fair Chance Act (FCA)
• Section: Office of Congressional Workplace Rights (United States)

The Fair Chance to Compete for Jobs

Act (FCA) Claim Form

Office of Co ngre ssio nal Wo rkplace Rig hts

Instructions

This for m may be use d by applic an ts for emp loyme nt vac anc ies with e mploying off ices

in th e legisla tive b ra nch to f ile a c laim with th e O ff ice of Congr ession al Workp lac e Rights

(O CW R) alle ging viola tion s( s) of the Fair C ha nce to C ompet e for J obs A ct (F CA ), which

is c odified a t Se ct ion 207 of the Con gre ssio nal A cc ounta bility Ac t (C AA) , 2 U. S.C.

§ 1316b. The FCA pr ohibits employing of fices from requesting that applicants for most

jobs disclose inf orma tion on their arrest and convic tion his tory be fore a conditional job

offer is made.

IM POR TANT NO TICE S

This for m ma y on ly be use d for FCA clai ms . Us e of an individual’s criminal history in

making e mployment decisions may, in s ome instances , violate the anti-discrimination

provisions of the CAA (whethe r or not it also violates the FCA). If you claim that an

employing office discriminated against you in its reques t for or use of criminal history

information, you mus t submit that discrimination claim on the form available on

the OCWR's File A Claim web page. For assistance, please contact the OCWR at (202)

724-9250.

You ha ve the righ t to re ceive ass istan ce fro m an OC WR Co nfid e ntia l Ad vis or.

If you ha ve que stion s or co nc er ns abo ut how t o co mple te this C laim For m, the

Administ ra tive Dis pute Re solution (A DR) p roc ess of th e O CWR, o r th e s pe cif ic

employme nt laws a pplica ble t o your w orkpla ce, a nd you do not ha ve a de signat ed attorney

re pres entative , you h av e th e r ight t o cons ult with an OCWR Confident ial Advis or , a t no

co st t o you. The C onfide ntia l Adviso r ca n inform y ou about y our right s u nde r th e FCA,

the C AA , a nd the OCWR’s proc edur es, d isc uss your c onc erns , a nd cons ult with y ou

re gard ing your c laims and t he options a vailab le to you unde r the FCA a nd CA A for

re solving t he m. T he Conf iden tia l A dvisor w ill p rov ide th es e se rvic es to you on a

priv ilege d a nd c onfide ntial basis .

Office of Congressional WorkplaceRig hts

110 SecondStreet, SE, RoomLA-200 | Washington, DC 20540-1999

(202) 724-9250 (O) | (202) 426-1913 (F)

www.ocwr.gov

OCWR FCA Claim Form 12/2021