Last Update: 9/1/05 (Transmittal II-6-13)
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SOCIAL SECURITY ADMINISTRATION _____________________________________________________________ | |
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Refer to: TAHB [SSN] [XSSN] |
Office of Hearings and Appeals 5107 Leesburg Pike Falls Church, VA 22041-3255 Telephone: 703-605-8000 Date: [Month, Day, Year] | |
| MEMORANDUM TO : |
Office of the Chief Administrative Law Judge Attention: Bias Complaint Officer |
| THROUGH : |
Executive Director Office of Appellate Operations |
| FROM : |
Appeals Council |
| SUBJECT : |
Complaint of Bias, Misconduct or Unfair Hearing on the Part of the Administrative Law Judge |
{1}
Please find attached copies of the material pertaining to the claims of:
Claimant: [Insert Claimant's Name]
SSN: [Insert Claimant's SSN]
ALJ: [Insert ALJ's Name]
[The Appeals Council found that the complainant's contention(s) is supported.] {Bias found.}
[The Appeals Council found that the complainant's contention(s) was not supported.] {Bias not found.}
[User keys in explanation for finding bias, misconduct, or unfair hearing]
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[Name] | |
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[Administrative Appeals Judge] or | |
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[Appeals Officer] {Only if Bias not found.} |
Attachments
BIAS COMPLAINT SUMMARY
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COMPLAINANT: |
[Last Name, First Name, & Middle Initial] | ||
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DATE OF COMPLAINT: |
[Date of the Complaint] | ||
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REQUEST FOR REVIEW FILED: |
[ ] Yes [ ] No | ||
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DATE OF REQUEST FOR REVIEW: |
[If filed, Specify Date] | ||
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CLAIMANT: |
[Name] |
SSN: |
[Number] |
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ATTORNEY/REP: |
[Name] |
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REGION: |
[Number] | CIRCUIT: | [Number] |
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ALJ: |
[Name] | ||
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DATE OF HEARING: [Date] |
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HO: [City] CODE: [Number] |
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BASIS FOR THE COMPLAINT: |
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RACE |
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ETHNICITY |
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GENDER |
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UNFAIR TREATMENT |
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OTHER |
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RACE and/or ETHNICITY OF THE CLAIMANT (Multiple Categories May Apply) | |||
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WHITE |
[ ] | ||
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BLACK or AFRICAN AMERICAN |
[ ] | ||
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ASIAN |
[ ] | ||
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NATIVE HAWAIIAN or OTHER PACIFIC ISLANDER |
[ ] | ||
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AMERICAN INDIAN |
[ ] | ||
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HISPANIC or LATINO |
[ ] | ||
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INFORMATION IS NOT AVAILABLE |
[ ] | ||
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Source of Data on Race/Ethnicity (for e.g., RSDI claim, SSI claim, re-determination, CDR, complaint or OTHER): [Indicate] | |||
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Date in which Race / Ethnicity DATA Collected: [Date] | |||
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GENDER OF CLAIMANT |
[ ] Male |
[ ] Female | |
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BIAS REVIEW COMPONENT: [Code] |
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REVIEW BEGINNING DATE: [Date] |
REVIEW ENDING DATE: [Date] | ||
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DISPOSITION OF BIAS COMPLAINT: [Indicate (e.g., Bias found. Bias not found.)] | |||