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Transportation Security Administration


INSTRUCTIONS: This form is to be used for alleged violations of Section V.C.9 of the Administrator’s Determination on Collective Bargaining and/or alleged violations of the Collective Bargaining Agreement (CBA) between the Transportation Security Administration (TSA) and the American Federation of Government Employees (AFGE). This form must be completed for each alleged violation and for each Bargaining Unit Employee (as applicable). Once completed, the form should be submitted to the National Resolution Center (NRC) at or via fax at (703) 603-4057.
NOTE: It is the designated representative’s obligation to provide all necessary information and documentation in support of the alleged violation as required by TSA Human Capital Management (HCM) policy, HCM 771-4, National Resolution Center. Failure to comply with these instructions could result in delay of processing and/or the dismissal of this Request For Review (RFR).

SECTION I. Filing Party/Submitter Information


Date of Alleged Violation:      

Contact Phone Number:      


Position: (select one)

 Bargaining Unit Employee (BUE)

 Designated AFGE Official
 Designated TSA Official

Airport Code (if applicable):    

BUE’s Name (if applicable):      

Current Position:      

Has an Informal Interest-based Discussion taken place between the two parties?  Yes  No

SECTION II. Determination-Related Allegations

Part A. Alleged Determination Violation?  Yes  No

Which subsection of Section V.C.9 of the Determination is alleged to be violated?

Relevant Section of V.C.9:


Provision(s) (if applicable):


Relevant Subsection (if applicable):


Part B. Alleged Collective Bargaining Agreement (CBA) Violation?  Yes  No

Which article of the CBA is alleged to be violated?



Provision(s) (if applicable):


Relevant subpart (if applicable):


SECTION III. Facts and Evidence
For alleged violations of the Determination or the CBA, please indicate the specific Article(s), provision(s) and relevant subsection(s), if applicable, that you are describing. You may attach additional sheets of paper, if necessary. Include the requested information as set forth below.

Part A. Provide a description of the alleged violation, including why you believe a violation occurred, the date(s) pertaining to the alleged violation, and any other relevant information, such as location, individual(s) present, and related circumstances. Attach supporting documentation, if available.


Part B. Identify individual(s) who may have relevant information, their contact information, and the type of information they may be able to provide.


Part C. Provide steps taken to resolve the alleged violation. If none were taken, explain why.


SECTION IV. Mediation or Facilitated Interest-based Discussion

What Are You Interested In? (check ONLY one)
 Facilitated Interest-based Discussion  Mediation  Not interested in Facilitated Interest-based Discussion or Mediation

SECTION V. Remedy Requested

Provide remedy or relief sought to resolve the alleged violation(s).


I hereby acknowledge that this information is true and accurate to the best of my knowledge and belief.


Designated Representative Name (print)

Signature (electronic submission signifies signature)


WARNING: This document may contain Privacy Act protected or other sensitive information and should be protected from unauthorized disclosure. TSA employees and contractors may share this information within DHS on a need-to-know basis. Disclosure outside of DHS must be approved by the Office of Chief Counsel or TSA Privacy Office.

TSA Form 1123-2 (12/12) [File: 1100.7.6-c] Page of

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