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Individual Complaint of Employment Discrimination
Individual Complaint of Employment Discrimination
OMB: 2105-0556
IC ID: 44070
OMB.report
DOT/OST
OMB 2105-0556
ICR 201210-2105-001
IC 44070
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2105-0556 can be found here:
2023-04-18 - Extension without change of a currently approved collection
2020-01-29 - Extension without change of a currently approved collection
Documents and Forms
Document Name
Document Type
Form DOT Form 1050-1
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:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
DOT Form 1050-1
EEO COUNSELOR CHECKLIST
DOT Form 1050-1 - EEO Counselor Checklist.docx
Yes
Yes
Fillable Printable
Form
DOT Form 1050-9
DESIGNATION OF REPRESENTATIVE FORM
DOT Form 1050-9 - DESIGNATION OF REPRESENTATIVE FORM.docx
Yes
Yes
Fillable Printable
Form
DOT Form 1050-2
Mediation Intake.doc
DOT Form 1050-2- Mediation Intake.doc
Yes
Yes
Fillable Printable
Form
DOT Form 1050-3
Agreement to Mediate
DOT Form 1050-3 - Agreement to Mediate.docx
Yes
Yes
Fillable Printable
Form
DOT Form 1050-4
Exit Survey for Mediation Participants
DOT Form 1050-4 - Exit Survey for Mediation Participants.doc
Yes
Yes
Fillable Printable
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
Yes
Yes
Fillable Printable
Form
DOT Form 1050-5
Extension of EEO Counseling
DOT Form 1050-5 - Extension of EEO Counseling.docx
Yes
Yes
Fillable Printable
Form
DOT Form 1050-7
Notice of Rights and Responsibilities
DOT Form 1050-7 - Notice of Rights and Responsibilities.doc
Yes
Yes
Fillable Printable
Form and Instruction
DOT Form 1050-8
Individual Complaint of Employment
DOT Form 1050-8 - Individual Complaint of Employment Discrimination.doc
Yes
Yes
Fillable Printable
Form
DOT Form 1050-10
Final Agency Decision Request Form
DOT Form 1050-10 - Final Agency Decision Request Form.doc
Yes
Yes
Fillable Printable
Form
DOT Form 1050-11
WAIVER OF RIGHT TO ANONYMITY
DOT Form 1050-11 - WAIVER OF RIGHT TO ANONYMITY.docx
Yes
Yes
Fillable Printable
Form
DOT Form 1050-12
Request for Mediation
DOT Form 1050-12 - Request for Mediation.docx
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 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
10
0
0
0
10
0
Annual IC Time Burden (Hours)
30
0
0
20
10
0
Annual IC Cost Burden (Dollars)
0
0
0
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.