Information Collection

Complaint of Employment Discrimination

IC 186321 under ICR 201412-2900-008 · OMB 2900-0716.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0716 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 4939 Complaint of Employment Discrimination	Form and Instruction
4939 Complaint of Employment Discrimination VA Form 4939.pdf vaww.va.gov/vaforms	Form and Instruction

IC Title:

Complaint of Employment Discrimination

Agency IC Tracking Number:

2900-0716

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 29 CFR 1614.106

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	4939	Complaint of Employment Discrimination	VA Form 4939.pdf	http://vaww.va.gov/vaforms	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 315

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	315	-104	419
Annual IC Time Burden (Hours)	158	-52	210
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.