Information Collection Request

Individual Complaint of Employment Discrimination

ICR 201210-2105-001 · OMB 2105-0556 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form DOT Form 1050-12 Request for Mediation Form Modified Available
Form DOT Form 1050-11 WAIVER OF RIGHT TO ANONYMITY Form Modified Available
Form DOT Form 1050-10 Final Agency Decision Request Form Form Modified Available
Form DOT Form 1050-9 DESIGNATION OF REPRESENTATIVE FORM Form Modified Available
Form DOT Form 1050-8 Individual Complaint of Employment Form and Instruction Modified Available
Form DOT Form 1050-7 Notice of Rights and Responsibilities Form Modified Available
Form DOT Form 1050-5 Extension of EEO Counseling Form Modified Available
Form DOT Form 1050-6 NOTICE OF RIGHT TO FILE A DISCRIMINATION COMPLAINT Form Modified Available
Form DOT Form 1050-4 Exit Survey for Mediation Participants Form Modified Repair queued
Form DOT Form 1050-3 Agreement to Mediate Form Modified Available
Form DOT Form 1050-2 Mediation Intake.doc Form Modified Available
Form DOT Form 1050-1 EEO COUNSELOR CHECKLIST Form Modified Repair queued
2105-0556_EEO_Forms_30_Day_Notice_2012-29483.pdf Supplementary Document Uploaded 2013-03-13 Available
GINA.pdf Supplementary Document Uploaded 2012-10-24 Available
Supporting Statement.MH.10-17-12.doc Supporting Statement A Uploaded 2012-10-17 Available
FR 60-day Notice 5-18-12.pdf Supplementary Document Uploaded 2012-10-17 Available
29 CFR Part 1614.pdf Supplementary Document Uploaded 2009-07-31 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
44070 Individual Complaint of Employment Discrimination Form ModifiedRequest for Mediation
44070 Individual Complaint of Employment Discrimination Form ModifiedWAIVER OF RIGHT TO ANONYMITY
44070 Individual Complaint of Employment Discrimination Form ModifiedFinal Agency Decision Request Form
44070 Individual Complaint of Employment Discrimination Form ModifiedDESIGNATION OF REPRESENTATIVE FORM
44070 Individual Complaint of Employment Discrimination Form and Instruction ModifiedIndividual Complaint of Employment
44070 Individual Complaint of Employment Discrimination Form ModifiedNotice of Rights and Responsibilities
44070 Individual Complaint of Employment Discrimination Form ModifiedExtension of EEO Counseling
44070 Individual Complaint of Employment Discrimination Form ModifiedNOTICE OF RIGHT TO FILE A DISCRIMINATION COMPLAINT
44070 Individual Complaint of Employment Discrimination Form ModifiedExit Survey for Mediation Participants
44070 Individual Complaint of Employment Discrimination Form ModifiedAgreement to Mediate
44070 Individual Complaint of Employment Discrimination Form ModifiedMediation Intake.doc
44070 Individual Complaint of Employment Discrimination Form ModifiedEEO COUNSELOR CHECKLIST

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
08/31/2014 36 Months From Approved
10 0 0
30 0 0
0 0 0





Reginfo record details
1
table that charts list of burden
IC Title Form No. Form Name
Individual Complaint of Employment Discrimination DOT Form 1050-1 , DOT Form 1050-9, DOT Form 1050-2, DOT Form 1050-3 , DOT Form 1050-4, DOT Form 1050-6, DOT Form 1050-5, DOT Form 1050-7 , DOT Form 1050-8, DOT Form 1050-10, DOT Form 1050-11, DOT Form 1050-12 ,   ,   ,   ,   ,   ,   ,   ,   ,   ,   ,  

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 10 0 0 0 0 10
Annual Time Burden (Hours) 30 0 0 0 20 10
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No