Americans with Disabilities Act Discrimination Complaint Form

Forms and Documents

Document Name	Status
Form 1190-0009 Americans with Disabilities Act Discrimination Complaint Form Form	Modified
1190-0009_2015 Compl Supporting Stmt A_052715.doc Supporting Statement A	2015-05-27
Certification Stmt 2015.doc Supplementary Document	2015-02-19
Privacy Release_A.doc Supplementary Document	2012-04-23
CFR Complaint.docx Supplementary Document	2010-05-26
ADA Law 12131.docx Supplementary Document	2010-05-26

IC Document Collections

IC ID	Document Title	Status
12906	Americans with Disabilities Act Discrimination Complaint Form Form	Modified

ICR Details

OMB Control No: 1190-0009	ICR Reference No: 201502-1190-001
Status: Historical Active	Previous ICR Reference No: 201201-1190-001
Agency/Subagency: DOJ/CRT	Agency Tracking No:
Title: Americans with Disabilities Act 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 with change	Conclusion Date: 07/09/2015
	Date Received in OIRA: 05/27/2015
Terms of Clearance: In accordance with 5 CFR 1320, this information collection as approved for 3 years. We encourage DOJ to include the option of electronically submitting attachment documents through the web-based form without requiring a two-step process of having to subsequently email attachments.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2018	36 Months From Approved	07/31/2015
Responses	9,100	0	5,000
Time Burden (Hours)	4,550	0	3,750
Cost Burden (Dollars)	0	0	0

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Abstract: Under title II of the Americans with Disabilities Act, an individual who believes that he or she has been subjected to discrimination on the basis of disability by a public entity may, by himself or herself or by an authorized representative, file a complaint. This information collection form has been developed to simplify this process for complainants.

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Authorizing Statute(s): US Code: 42 USC 12131 Name of Law: Americans with Disabilities Act
  

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:
	80 FR 10513	02/26/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 25324	05/04/2015
Did the Agency receive public comments on this ICR? Yes

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

IC Title	Form No.	Form Name
Americans with Disabilities Act Discrimination Complaint Form	1190-0009	Americans with Disabilities Act 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	9,100	5,000	0	4,100	0	0
Annual Time Burden (Hours)	4,550	3,750	0	800	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: There is a change in burden due to the increase number of complaints filed.

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Annual Cost to Federal Government: $245,700

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: 05/27/2015

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