Fed Cir. R. 15(c) Statement Concerning Discrimination

• Legal Form Number: 10
• Date: 01 July 2020
• Court: U.S. Court of Appeals — Federal Circuit
• Section: United States Court of Appeals for the Federal Circuit

FORM 10. Statement Concerning DiscriminationForm 10(p. 1)

July 2020

UNITED STATES COURT OF APPEALS

FOR THE FEDERAL CIRCUIT

FED. CIR. R. 15(c) STATEMENT CONCERNING DISCRIMINATION

Case Number:

Short Case Caption:

Name of Petitioner:

Purpose:This form is to help determine the proper forum for judicial review of a

decision of the Merit Systems Protection Board(MSPB)or an Arbitrator, and in

particular, those cases in which the federal employee has attributed theadverse

employment action, in whole or in part, to bias based on race,color, religion,sex, age,

national origin,or handicapping condition, in violation of federal antidiscrimination

laws.

This court, while empowered to review MSPB and Arbitrator decisionsdealing solely

withcivil-service claims, lacks authority to decide matters in whichclaims arising

under federal discrimination lawshave been asserted and not abandoned. Rather,

the proper forum for judicial review of such matters is a federal districtcourt. This

form will assistthe courtindeterminingwhether it needs to transfera matterto a

district court.

Instructions: Complete Section A.Complete Sections B and C only as directed by

your answer to Section A.

Section A

Before the MSPB or the Arbitrator, did you argue that the adverse employment

action (1) was attributable to discrimination on the basis of race, color, religion,

sex, age, national origin, or handicapping condition or (2) was retaliation for

pursuing EqualEmployment Opportunity activity?

☐Yes (complete Sections B and C)☐No (ignore Sections B and C)