Information Collection

Civil Rights Discrimination Complaint

IC 28940 under ICR 201104-2900-003 · OMB 2900-0662.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0662 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-0381 Civil Rights Discrimination Complaint	Form
10-0381 CIVIL RIGHTS DISCRIMINATION COMPLAINT 10-0381-fill.pdf www.va.gov/vaforms	Form
10-0381 Discrimination Complaint VA Form 10-0381.pdf	Form

IC Title:

Civil Rights Discrimination Complaint

Agency IC Tracking Number:

2900-0662

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation: 38 CFR 18.501 45 CFR 90 38 CFR 15 38 CFR 18.401 38 CFR 18.1

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	10-0381	CIVIL RIGHTS DISCRIMINATION COMPLAINT	10-0381-fill.pdf	http://www.va.gov/vaforms	Yes	No	Fillable Printable
Form	10-0381	Discrimination Complaint	VA Form 10-0381.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Litigant, Tort Claimant, EEO Complainant and Third Party Recovery Files-VA

FR Citation: 47 FR 8

Number of Respondents: 183

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	183	183
Annual IC Time Burden (Hours)	46	46
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.