Disciplinary Review Board Appeal

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					                                                                            Disciplinary Review Board Appeal

INSTRUCTIONS: This form is to be completed by an employee to initiate processing of a Disciplinary Review Board
(DRB) appeal. The information collected will be used to help determine whether the DRB has jurisdiction over the
appeal, whether it has been filed within the applicable time limit, and what claims and defenses are being raised. Use of
this form is not required to file an appeal with the DRB, but any appeal must still comply with applicable TSA directives
and policies. Please contact the DRB Coordinator at 571-227- 4704, or send an email to DRB.drb@dhs.gov with
questions or concerns.

Filing an appeal: Appeals must be filed in accordance with the provisions of TSA MD 1100.77-1, Disciplinary Review
Board. Failure to provide any of the required materials/information may result in rejection of this appeal due to an
incomplete submission.

Appeals may be filed by mail, e-mail, facsimile, commercial overnight delivery, or personal delivery. Submit one (1)
copy of both the appeal and all attachments. All submissions must be legible and made on 8 1/2" x 11" paper.
Responses may be supplemented on a separate sheet of paper. Please include your name and address at the top of each
supplemental page.

MAIL: DHS -Transportation Security Administration, Assistant Administrator for Human Capital, Office of Human
Capital (TSA-30), Attn: Disciplinary Review Board Coordinator, 601 S. 12th Street, Arlington, VA 20598

EMAIL: DRB.drb@dhs.gov

FACSIMILE: (571) 227-1389

Filing Deadline: An appeal must be filed no-later-than 30 calendar days after the effective date of the action being
appealed. (Exception: Any appeal of the reason for imposing the indefinite suspension must be filed within 30 days of the
effective date of the action. However, the continuation of an indefinite suspension may be appealed at anytime during the
indefinite suspension, and within 30 days after the conclusion of the indefinite suspension.)

Computing the time period for filing an appeal: The first calendar day after the effective date of the action is the first
day of the 30-day filing period. If the filing period ends on a Saturday, Sunday, or Federal holiday, the appeal must be
filed by the next business day. For personal delivery, the appeal is accepted as filed for processing by the DRB on the
date the DRB Coordinator receives it. If delivery is by mail or commercial carrier, the date the appeal is postmarked (or
accepted for delivery by the carrier) is considered the date the appeal is filed. Appeals filed by e-mail or facsimile must
be sent to the DRB Coordinator no later than 12:00 a.m. Eastern Standard Time (E.S.T.) on the last day of the filing
period.i

Requesting Extensions: The DRB must receive extension requests prior to close of the 30 day filing period. Requests
must be in writing and may be submitted via email, facsimile, mail, or commercial carrier to one of the above addresses.
State the reason(s) more time is being requested, and the additional amount of time being requested. Extensions will not
automatically be granted. Requestors must justify the need for an extension by demonstrating good cause for the
extension request.ii

NOTE: The DRB is not authorized to decide Equal Employment Opportunity (EEO) issues. If you include complaints of
prohibited discrimination in your appeal, the DRB will not address them in its decision on your appeal.

If you file an informal EEO complaint regarding the matter appealed, the DRB will defer deciding your appeal until the
conclusion of the informal EEO complaint process. If you file a formal EEO complaint with the Office of Civil Rights
and Liberties concerning the same matter being appealed, the DRB will dismiss your appeal for lack of jurisdiction.iii

If you believe management’s action against you was due to prohibited discrimination, you must contact an EEO counselor
within 45 days of the effective date of the action.


                                                        Page 1 of 4
TSA Form 1177-1, 01/10 [FILE: 1100.7.4]
If any of the below information changes while the appeal is pending, you must notify the DRB in writing of the change(s).

Please type or print all responses legibly.
Section 1—Appellant and Agency Information
1.   Name:
              (last, first, middle initial)
2.   Current Address:

Street                                               City                                                State                       Zip
3. Phone Numbers (include area code) and E-Mail Address:
Home:                              Work:                              Other:                             Facsimile
E-mail Address:

4.   Name and address of the office that took the action or made the decision you are appealing:

Transportation Security Administration, Airport Code


Street                                                        City                                       State                       Zip
5.   Federal employment status at the time of the action or decision being appealed:           Permanent                Temporary
6.   Series, title, pay band, and duty station at the time of the action or decision being appealed :

Occupational Series:                    Position Title:                                 Pay Band:                    Duty Station:


7.    Length of Government service (in years):                         8.   Length of service with TSA (in years):

9.   Were you serving in a trial period at the time of the action or decision you are appealing?           Yes              No
10. I certify that all of the statements made in this form and any attachments are true, complete, and correct to the best of my
    knowledge and belief.


_____________________________________________                                  _______________________
Signature of Appellant or Representative                                       Date
Section 2—Agency Personnel Action
Complete this part to provide information relating to the type of action you are appealing, the corrective action you are seeking, and
any other related complaints that you have filed (e.g., EEO, OSC, etc.). If yes please indicate:

11. Check the box(es) that best describe(s) the personnel action(s) you are appealing. Attach a copy of the proposal letter and decision
    letter (if any). If an SF-50 or its equivalent was issued and is available, attach it now; however, DO NOT delay filing your appeal
    because you do not have an SF-50. You may submit the SF-50 when it becomes available.

     Removal        Involuntary Demotion for Performance/Conduct                 Suspension (14+ days)           Suspension (Indefinite)

     Other action, describe:

12. Proposal letter date of receipt (if any) (month, day, year):
13. Agency’s final decision letter date of receipt (if any) (month, day, year):
14. Agency’s action or decision effective date (month, day, year):
15. Prior to filing this appeal, did you and the agency mutually agree, in writing, to try to resolve the matter through an alternative
    dispute resolution (ADR) process or any other settlement process?

     Yes (Attach a copy of the agreement)                                   No


                                                                   Page 2 of 4
TSA Form 1177-1, 01/10 [FILE: 1100.7.4]
16. Contents of Appeal.

State your appeal below; you may attach continuation pages if necessary and any supporting documents or statements. The appeal
should contain sufficient information for the Board to understand the reason why you are appealing the management action. Attach
additional information on plain paper, and enclose any statements, documents, or physical evidence you want the DRB to
consider.

    a) If you dispute the facts in the charge(s) or specification(s), in the decision notice, state your reasoning. You may provide
       supporting documents or statements.
    b)


    c) If you believe the penalty is too harsh, you may provide the DRB with your reasons. You may provide supporting documents
       or statements.
    d)


    e) If there is any other information you believe the DRB should consider when deciding your appeal, please explain.



    f)   If there were witnesses to a relevant event, you can ask them to provide a dated and signed statement about what they saw or
         heard, and submit the statement with your appeal.



    g) Please explain what action you are seeking from the DRB and why.



    h) Suggested Attachments. If available, your appeal should include copies of: the proposal notice, if any; your written reply, if
       any; the decision notice; and a copy of your most recent SF-50, Notice of Personnel Action. The appeal should provide any
       evidence, such as signed, dated, legible witness statements, or other documentary or physical evidence supporting your
       assertions in the appeal.

    i)   Unavailable evidence. If you believe the Board should consider evidence that you have not been able to provide, you should
         specifically identify the documents or physical evidence, explain why you have not been able to provide it, and who has it or
         where it is located.

Section 3—Designation of Representative
Complete boxes 18-20 if you are designating a person who has agreed to represent you in your appeal before the Board. By
designating a representative, you agree to allow the TSA to give your representative all information concerning the appeal. Any
changes of this designation must be sent in writing to the DRB.iv
17. Do you wish to designate an individual to represent you in this proceeding before the Board? (You may designate a representative
    at any time. However, the processing of your appeal will not normally be delayed because of any difficulty you may have in
    obtaining a representative.)

     Yes (Complete the information below and sign)              No

18. Representative’s Name:
                              (last, first, middle initial)
19. Representative’s Current Address:

Street                                                  City                                       State                   Zip
20. Representative’s Phone Numbers (include area code) and E-Mail Address:
Home:                            Work:                            Other:                           Facsimile
E-mail Address:




                                                              Page 3 of 4
TSA Form 1177-1, 01/10 [FILE: 1100.7.4]
21. I hereby designate        to serve as my representative during the course of this appeal. I understand that my representative is
    authorized to act on my behalf. In addition, I specifically delegate to my representative the authority to settle this appeal on my
    behalf. I understand that any limitation on this settlement authority must be filed in writing with the Board.



________________________________________________________                             ___________________
Appellant’s Signature                                                                  Date
22. I certify that all of the statements made in this form and any attachments are true, complete, and correct to the best of my
    knowledge and belief.


_____________________________________________                             _______________________
Signature of Appellant or Representative                                  Date

PRIVACY ACT STATEMENT: AUTHORITY: Section 111(d) of the Aviation and Transportation Security Act. PRINCIPAL
PURPOSE(S): to initiate processing of a Disciplinary Review Board (DRB) appeal. ROUTINE USE(S): To disclose information
during proceedings before any court, adjudicative or administrative body, and for routine uses identified in DHS/ALL-018 Department
of Homeland Security Grievances, Appeal and Disciplinary Action System of Records. DISCLOSURE: Voluntary. The use of this
form is not required to file an appeal with the DRB, but any appeal must comply with applicable TSA directives and policies.


i
    See Handbook to TSA MD 1100.77- 1, Sections B and C
ii
    See Handbook to TSA MD 1100.77- 1, Section C(4)
iii
    See Handbook to TSA MD 1100.77- 1, Section G
iv
    See TSA MD 1100.63-3, Employee Representation




                                                               Page 4 of 4
TSA Form 1177-1, 01/10 [FILE: 1100.7.4]

				
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