Information Collection

Individual Complaint of Employment Discrimination

IC 44070 under ICR 201210-2105-001 · OMB 2105-0556.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2105-0556 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DOT Form 1050-1 EEO COUNSELOR CHECKLIST Individual Complaint of Employment Discrimination	Form
Form DOT Form 1050-2 Mediation Intake.doc Individual Complaint of Employment Discrimination	Form
Form DOT Form 1050-3 Agreement to Mediate Individual Complaint of Employment Discrimination	Form
Form DOT Form 1050-4 Exit Survey for Mediation Participants Individual Complaint of Employment Discrimination	Form
Form DOT Form 1050-6 NOTICE OF RIGHT TO FILE A DISCRIMINATION COMPLAINT Individual Complaint of Employment Discrimination	Form
Form DOT Form 1050-5 Extension of EEO Counseling Individual Complaint of Employment Discrimination	Form
Form DOT Form 1050-7 Notice of Rights and Responsibilities Individual Complaint of Employment Discrimination	Form
Form DOT Form 1050-8 Individual Complaint of Employment Individual Complaint of Employment Discrimination	Form and Instruction
Form DOT Form 1050-9 DESIGNATION OF REPRESENTATIVE FORM Individual Complaint of Employment Discrimination	Form
Form DOT Form 1050-10 Final Agency Decision Request Form Individual Complaint of Employment Discrimination	Form
Form DOT Form 1050-11 WAIVER OF RIGHT TO ANONYMITY Individual Complaint of Employment Discrimination	Form
Form DOT Form 1050-12 Request for Mediation Individual Complaint of Employment Discrimination	Form
DOT Form 1050-1 EEO COUNSELOR CHECKLIST DOT Form 1050-1 - EEO Counselor Checklist.docx	Form
DOT Form 1050-2 Mediation Intake.doc DOT Form 1050-2- Mediation Intake.doc	Form
DOT Form 1050-3 Agreement to Mediate DOT Form 1050-3 - Agreement to Mediate.docx	Form
DOT Form 1050-4 Exit Survey for Mediation Participants DOT Form 1050-4 - Exit Survey for Mediation Participants.doc	Form
DOT Form 1050-6 NOTICE OF RIGHT TO FILE A DISCRIMINATION COMPLAINT DOT Form 1050-6 - NOTICE OF RIGHT TO FILE A DISCRIMINATION COMPLAINT.docx	Form
DOT Form 1050-5 Extension of EEO Counseling DOT Form 1050-5 - Extension of EEO Counseling.docx	Form
DOT Form 1050-7 Notice of Rights and Responsibilities DOT Form 1050-7 - Notice of Rights and Responsibilities.doc	Form
DOT Form 1050-8 Individual Complaint of Employment DOT Form 1050-8 - Individual Complaint of Employment Discrimination.doc	Form and Instruction
DOT Form 1050-9 DESIGNATION OF REPRESENTATIVE FORM DOT Form 1050-9 - DESIGNATION OF REPRESENTATIVE FORM.docx	Form
DOT Form 1050-10 Final Agency Decision Request Form DOT Form 1050-10 - Final Agency Decision Request Form.doc	Form
DOT Form 1050-11 WAIVER OF RIGHT TO ANONYMITY DOT Form 1050-11 - WAIVER OF RIGHT TO ANONYMITY.docx	Form
DOT Form 1050-12 Request for Mediation DOT Form 1050-12 - Request for Mediation.docx	Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Individual Complaint of Employment Discrimination

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 29 CFR 1614

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	DOT Form 1050-1	Yes	Yes	Fillable Printable
Form	DOT Form 1050-2	Yes	Yes	Fillable Printable
Form	DOT Form 1050-3	Yes	Yes	Fillable Printable
Form	DOT Form 1050-4	Yes	Yes	Fillable Printable
Form	DOT Form 1050-6	Yes	Yes	Fillable Printable
Form	DOT Form 1050-5	Yes	Yes	Fillable Printable
Form	DOT Form 1050-7	Yes	Yes	Fillable Printable
Form and Instruction	DOT Form 1050-8	Yes	Yes	Fillable Printable
Form	DOT Form 1050-9	Yes	Yes	Fillable Printable
Form	DOT Form 1050-10	Yes	Yes	Fillable Printable
Form	DOT Form 1050-11	Yes	Yes	Fillable Printable
Form	DOT Form 1050-12	Yes	Yes	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Workforce Management

Subfunction: Labor Rights Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

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	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	10	0	10
Annual IC Time Burden (Hours)	30	20	10
Annual IC Cost Burden (Dollars)	0	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.

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