Discrimination Complaint Form

Forms and Documents

Document Name	Status
Form SSA-437 Discrimination Complaint Form Form and Instruction	Modified
6-26-13 updated addendum.docx Supplementary Document	2013-07-08
Supporting Statement (revised).doc Supporting Statement A	2013-07-08

IC Document Collections

IC ID	Document Title	Status
9560	Discrimination Complaint Form Form and Instruction	Modified

ICR Details

OMB Control No: 0960-0585	ICR Reference No: 201303-0960-011
Status: Historical Active	Previous ICR Reference No: 201001-0960-008
Agency/Subagency: SSA	Agency Tracking No:
Title: Discrimination Complaint Form
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/13/2013
	Date Received in OIRA: 07/08/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2016	36 Months From Approved	08/31/2013
Responses	140	0	140
Time Burden (Hours)	140	0	140
Cost Burden (Dollars)	0	0	0

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Abstract: SSA collects information on Form SSA–437 to investigate and formally resolve complaints of discrimination based on disability, race, color, national origin (including limited English proficiency), sex, sexual orientation, age, religion, or retaliation for having participated in a proceeding under this administrative complaint process in connection with an SSA program or activity. SSA also requests the information from the SSA-437 to review, investigate and decide complaints alleging discrimination on the basis of status as a parent in education, training programs, or activities conducted by SSA. Individuals who believe SSA discriminated against them on any of the above bases may file a written complaint of discrimination. SSA uses the information to identify the complainant; identify the alleged discriminatory act; ascertain the date of such alleged act; obtain the identity of any individual(s) with information about the alleged discrimination; and ascertain other relevant information that would assist in the investigation and resolution of the complaint. Respondents are individuals who believe SSA or SSA employees, contractors or agents in programs or activities conducted by SSA discriminated against them.

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Authorizing Statute(s): US Code: 5 USC 301 Name of Law: The Federal Housekeeping Statute
   US Code: 29 USC 794(a) Name of Law: Rehabilitation Act
   US Code: 42 USC 902(a)(5) Name of Law: Social Security Act
   EO: EO 13166 Name/Subject of EO: Improving Access to Services for Persons With Limited English Proficiency
   EO: EO 13160 Name/Subject of EO: Ensuring Equal Opportunity in Federally Conducted Education and Training Programs
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 19794	04/02/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 40819	07/08/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Discrimination Complaint Form	SSA-437	Discrimination Complaint Form

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ICR Summary 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	140	140	0	0	0	0
Annual Time Burden (Hours)	140	140	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $7,500

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 07/08/2013

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