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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] | |
Last Update: 9/1/05 (Transmittal II-6-13)
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SOCIAL SECURITY ADMINISTRATION _____________________________________________________________ | |
|
Refer to: TAHB [SSN] [XSSN] |
Office of Hearings and Appeals 5107 Leesburg Pike Falls Church, VA 22041-3255] | |
| 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:
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Claimant: |
[Insert Claimant's Name] |
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SSN: |
[Insert Claimant's SSN]] |
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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] [Administrative Appeals Judge] or [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.)] | ||