Explain the circumstances that make the collection of information necessary. Identify legal or administrative requirements that necessitate the collection of information.
Information contained on the complaint form is voluntarily submitted by veterans and other VHA customers who believe that their civil rights were violated by agency employees while receiving medical care or services in VA medical centers, or institutions such as state homes that receive federal financial assistance from VA. No information is collected from the form to compile any kind of personal data or statistics.
2. Indicate how, by whom, and for what purposes the information is to be used; indicate actual use the agency has made of the information received from current collection.
The complaint form is used by patients and other VHA customers, given to them either in person or mailed by the EEO Program Manager, to a file formal complaint for alleged violations of their civil rights pertaining to race, color, sex, national origin, age, disability, or reprisal. VHA Directive 2002-037 is based on the following statutory authorities:
38 CFR Ch. 1, Part 18.1—Nondiscrimination in Federally-Assisted Programs of the Department of Veterans Affairs—Effectuation of Title VI of the Civil Rights Act of 1964, Sec.602, 78 Stat. 252 (42 U.S.C. 2000d-1.
38 CFR Ch. 1, Part 18.401—Nondiscrimination in Federally-Assisted Programs of the Department of Veterans Affairs—Effectuation of Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. 794; 42 U.S.C. 2000d-1 to 2000d-4, 6101-6107.
38 CFR Ch. 1, Part 18.501—Nondiscrimination on the Basis of Age under the Age Discrimination Act of 1975 and the government wide age discrimination regulations at 45 CFR part 90. (42 U.S.C. 6101-6107).
38 CFR Ch.1, Part 15—Enforcement of Nondiscrimination on the Basis of Handicap in Programs or Activities Conducted by the Department of Veterans Affairs. (29 U.S.C. 794).
3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g. permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also described any consideration of using information technology to reduce burden.
The use of VA Form 10-0381 does not involve the use of automated, electronic, mechanical, or other technological collection techniques or any other form of information technology. The form may be obtained by complainants from the office of the facility Equal Employment Opportunity (EEO) Manager. The form does not constitute a reporting burden; it was developed to reduce the complainant’s burden in attempting to articulate an event believed to be discriminatory. The form helps the complainant to provide only the information necessary to make a determination whether the complaint warrants airing in a civil rights arena or in some other forum. Due to the low usage of the form, no consideration was given to using information technology to disseminate the form.
4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.
No other form exists to collect the information needed to process a Civil Rights Discrimination Complaint.
5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.
No small businesses or other small entities are impacted by this information collection.
6. Describe the consequences to Federal program or policy activities if the collection is not conducted or is conducted less frequently as well as any technical or legal obstacles to reducing burden.
VHA would not be responsive to the needs of the complainant if this data were collected less frequently.
7. Explain any special circumstances that would cause an information collection to be conducted more often than quarterly or require respondents to prepare written responses to a collection of information in fewer than 30 days after receipt of it; submit more than an original and two copies of any document; retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than three years; in connection with a statistical survey that is not designed to produce valid and reliable results that can be generalized to the universe of study and require the use of a statistical data classification that has not been reviewed and approved by OMB.
There are no such special circumstances.
8. a. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the sponsor’s notice, required by 5 CFR 1320.8(d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the sponsor in responses to these comments. Specifically address comments received on cost and hour burden.
The notice of Proposed Information Collection Activity was published in the Federal Register on January 8, 2008, 73FR5, pages 1399-1400. We received no comments in response to this notice.
b. Describe efforts to consult with persons outside the agency to obtain their views on the availability of data, frequency of collection, clarity of instructions and recordkeeping, disclosure or reporting format, and on the data elements to be recorded, disclosed or reported. Explain any circumstances which preclude consultation every three years with representatives of those from whom information is to be obtained.
The form was devised to collect only information proscribed in VA civil rights regulations. Data collection, disclosure and reporting were not the purpose of devising this form. Therefore, no efforts were made to consult with persons outside the agency to obtain their views.
9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.
No payment or gift is provided to respondents.
10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statue, regulation, or agency policy.
Assurances of confidentiality are provided to complainants under the two laws governing personal information submitted to VA: The Privacy Act of 1974 (5 U.S.C. §552a), and the Freedom of Information Act (5 U.S.C. §552). Respondents are informed that the information collected will become part of a record that complies with the Privacy Act of 1974. These forms are part of the system of records identified as 16VA026 Litigant, Tort Claimant, EEO Complainant and Third Party Recovery Files-VA and 63VA05 Grievance Records-VA published in the Federal Register as set forth in the 2003 Compilation of Privacy Act Issuances via online GPO access at http://www.access.gpo.gov/su_docs/aces/2003_pa.html
11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private; include specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.
There are no questions of a sensitive nature.
12. Estimate of the hour burden of the collection of information:
183 respondents x 1 response x 15 minutes / 60 = 46 hours
b. If this request for approval covers more than one form, provide separate hour burden estimates for each form and aggregate the hour burdens in Item 13 of OMB 83-I.
This request covers only one form.
c. Provide estimates of annual cost to respondents for the hour burdens for collections of information. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 14.
The total cost to respondents is $690 (46 responses x $15 per hour).
13. Provide an estimate of the total annual cost burden to respondents or recordkeepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).
a. There is no capital, start-up, operation or maintenance costs.
b. Cost estimates are not expected to vary widely. The only cost is that for the time of the respondent.
c. There are no anticipated capital start-up cost components or requests to provide information.
14. Provide estimates of annual cost to the Federal Government. Also, provide a description of the method used to estimate cost, which should include quantification of hours, operation expenses (such as equipment, overhead, printing, and support staff), and any other expense that would not have been incurred without this collection of information. Agencies also may aggregate cost estimates from Items 12, 13, and 14 in a single table.
|
Salary/HR |
Responses |
Equals |
Minutes |
÷ by |
Total |
Postage |
200 x $0.41 |
$82.00 |
||||
Administrative Review (GS 7/5) |
$21.36 |
183 |
$3,908.88 |
15 |
60 |
$977.22 |
EEO Manager Review (GS-12/5) |
$37.89 |
183 |
$6,933.87 |
20 |
60 |
$2311.29 |
VAMC Director Review (GS/14/5) |
$53.24 |
60 |
$3,194.40 |
30 |
60 |
$1597.20 |
HQ Expert Review (GS-15/10) |
$71.39 |
20 |
$1,427.80 |
40 |
60 |
$951.86 |
TOTAL |
|
|
|
|
|
$5,919.57 |
15. Explain the reason for any burden hour changes since the last submission.
There are no changes in burden hour.
16. For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection of information, completion of report, publication dates, and other actions.
We do not plan to publish this data.
17. If seeking approval to omit the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.
We do not seek approval to eliminate the expiration date from the form.
18. Explain each exception to the certification statement identified in Item 19, “Certification for Paperwork Reduction Act Submissions,” of OMB 83-I.
There are no exceptions.
No statistical methods are used in this data collection.
Page
| File Type | application/msword |
| File Title | Bold black = OMB questions |
| Author | vhacobickoa |
| File Modified | 2008-03-27 |
| File Created | 2008-03-27 |