DHS Individual Complaint of Employment Discrimination

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form DHS Form 3090 DHS Individual Complaint of Employment Discrimination	Form and Instruction	Modified	Available
Published 30-day notice 1610-0001.pdf	Supplementary Document	Uploaded 2008-04-21	Available
PART 1614--FEDERAL SECTOR EQUAL EMPLOYMENT OPPORTUNITY.pdf	Supplementary Document	Uploaded 2008-03-31	Available
1610-0001 Published 60-day notice 01-22-2008.pdf	Supplementary Document	Uploaded 2008-03-31	Available
1610-0001 Supporting Statement 03312008.doc	Supporting Statement A	Uploaded 2008-03-31	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
20218	DHS Individual Complaint of Employment Discrimination	Form and Instruction	Modified

ICR Details

OMB Control No: 1610-0001	ICR Reference No: 200803-1610-001
Status: Historical Active	Previous ICR Reference No: 200501-1610-001
Agency/Subagency: DHS/OCR	Agency Tracking No:
Title: DHS Individual Complaint of Employment Discrimination
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/24/2008
	Date Received in OIRA: 04/21/2008
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2011	36 Months From Approved	06/30/2008
Responses	1,200	0	1,200
Time Burden (Hours)	600	0	600
Cost Burden (Dollars)	0	0	0

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Abstract: This form provides information necessary for processing formal complaints of employment discrimination in accordance with EEOC Management Directive (EEO-MD) 110, and 29 C.F.R. part 1614.

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Authorizing Statute(s): US Code: 42 USC 2000e Name of Law: Title VII of the Civil Rights Act
   US Code: 29 USC 621 Name of Law: Age Discrimination in Employment Act
   US Code: 29 USC 791 Name of Law: Rehabilitation Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 3738	01/22/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 21147	04/18/2008
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
DHS Individual Complaint of Employment Discrimination	DHS Form 3090	DHS Individual Complaint of Employment Discrimination

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,200	1,200	0	0	0	0
Annual Time Burden (Hours)	600	600	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $28,146

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 04/21/2008

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