U.S. Department of Agriculture
Natural Resources Conservation Service
1. Complainant name
2. Date of initial contact
3. Expiration of 30-day counseling period
4. Proposed extension expires
(Date shown in #2 plus 30 calendar days)
(Date shown in #3 plus no more than 60 calendar days)
Agreement to extend counseling/participate in mediation
This form records the agreement by the complainant (#1 above) and the Civil Rights Division to
extend counseling beyond the 30-day counseling period authorized under 29 CFR 1614.
The signatures below represents an agreement between the complainant and the Civil Rights Division
that the counseling period will or may be extended for a period of no more than 60 days from the
expiration date shown in #3 above to the date proposed in #4, to permit mediation to take place in an
effort to resolve this complaint.
The counseling period may not be extended unless both signatures from the complainant(s) and
counselor(s) appear on this form.
The complainant understands that:
1. Participation in mediation is voluntary and he/she may terminate it at any time.
2. The mediator has no authority to make decisions on issues raised nor act as an advocate or
attorney for either party in the mediation. The complainant may consult with a designated
representative selected by the complainant at no cost to the government.
If he/she and the agency are unable to reach a resolution in mediation, unresolved issues may be
submited through the EEO complaint process. The complainant will be issued the Notice of Right
to File a Formal Discrimination Complaint letter upon termination of the mediation process or on
the 60th day of extended counseling, whichever comes first.
Counselor typed or printed name