Complaint of Employment Discrimination

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0716 can be found here:

Documents and Forms

Document Name Document Type
Form 4839 Complaint of Employment Discrimination Form and Instruction
4839 Complaint of Employment Discrimination VA4939.pdf vaww.va.gov/vaforms Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Complaint of Employment Discrimination	Agency IC Tracking Number:	2900-0716

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 29 CFR 1614.106

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	4839	Complaint of Employment Discrimination	VA4939.pdf	http://vaww.va.gov/vaforms	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 419	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	419	95	324
Annual IC Time Burden (Hours)	210	48	162
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.