Civil Rights Discrimination Complaint

Forms and Documents

Document Name	Status
Form 10-0381 Civil Rights Discrimination Complaint Form	Modified
2900-0662 justification_20140521 OIRA 8-6-14.docx Supporting Statement A	2014-08-07

IC Document Collections

IC ID	Document Title	Status
28940	Civil Rights Discrimination Complaint Form	Modified

ICR Details

OMB Control No: 2900-0662	ICR Reference No: 201401-2900-009
Status: Historical Active	Previous ICR Reference No: 201104-2900-003
Agency/Subagency: VA	Agency Tracking No: 2900-0662
Title: Civil Rights Discrimination Complaint
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 08/11/2014
	Date Received in OIRA: 06/24/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2017	36 Months From Approved	08/31/2014
Responses	183	0	183
Time Burden (Hours)	46	0	46
Cost Burden (Dollars)	0	0	0

---

Abstract: This collection is used to simplify the complainant's burden in filing a Civil Rights Discrimination complaint by identifying the information necessary to resolve the complaint.

---

Authorizing Statute(s): US Code: 42 USC 2000d-1 Name of Law: Federal authority and financial assistance to programs or activities by way of grant, loan, or contr
   US Code: 42 USC 2000d-2 Name of Law: Judicial review; administrative procedure provisions
   US Code: 42 USC 2000d-3 Name of Law: Construction of provisions not to authorize administrative action with respect to employment practic
   US Code: 42 USC 2000d-4 Name of Law: Federal authority and financial assistance to programs or activities by way of contract of insurance
   US Code: 42 USC 6101 Name of Law: Statement of purpose
   US Code: 42 USC 6102 Name of Law: Prohibition of discrimination
   US Code: 42 USC 6103 Name of Law: Regulations
   US Code: 42 USC 6104 Name of Law: Enforcement
   US Code: 42 USC 6105 Name of Law: Judicial review
   US Code: 42 USC 6106 Name of Law: Study of discrimination based on age
   US Code: 42 USC 6107 Name of Law: Definitions
   US Code: 29 USC 794 Name of Law: Nondiscrimination under Federal grants and programs
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 3270	01/17/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 30696	05/28/2014
Did the Agency receive public comments on this ICR? Yes

---

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

IC Title	Form No.	Form Name
Civil Rights Discrimination Complaint	10-0381	Civil Rights Discrimination Complaint

---

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	183	183	0	0	0	0
Annual Time Burden (Hours)	46	46	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:

---

Annual Cost to Federal Government: $6,324

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

---

Common Form ICR:  No

---

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: 06/24/2014

---