This information
collection is approved through 4-99 as revised by the 3/23, 3/24
SSA fax and under the following conditions: Upon submission, SSA
will provide an analysis of comments from the NPRM that relate to
this form and make any necessary changes. In addition, SSA will
immediately modify question 10 to read: "Are you filing this
discrimination complaint because your benefits were ceased?"
Inventory as of this Action
Requested
Previously Approved
03/31/2001
03/31/2001
250
0
0
250
0
0
0
0
0
The information will be used by SSA to
investigate and informally resolve complaints of discrimination
based on race, color, national origin, sex, age, religion, and
retaliation in any program activity conducted by SSA. The
information will be used to identify the alleged discriminatory
act, ascertain the date of the alleged act, obtain the identity of
the individual(s)/ facility/component that allegedly discriminated,
and ascertain other relevant information that would assist in the
investigation and resolution of the complaints.
On behalf of this Federal agency, I certify that
the collection of information encompassed by this request complies
with 5 CFR 1320.9 and the related provisions of 5 CFR
1320.8(b)(3).
The following is a summary of the topics, regarding
the proposed collection of information, that the certification
covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a
benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control
number;
If you are unable to certify compliance with any of
these provisions, identify the item by leaving the box unchecked
and explain the reason in the Supporting Statement.