NASA Complaint of Discrimination Form 1355

Forms and Documents

Document	Type	Status	Availability
Form 1355P NASA Form	Form	New	Available
EEOC Concurrence on the NF1355P as of 01.06.2016.docx	Supplementary Document	Uploaded 2016-01-06	Available
EEOC comment on NASA Form 1355P. dated 12.23.2015.pdf	Supplementary Document	Uploaded 2015-12-28	Repair queued
30-day FRN. Compaints of Discrimination. 09.14.2015.pdf	Supplementary Document	Uploaded 2015-09-14	Available
NASA Response to EEOC Comments on 60-day FRN..pdf	Supplementary Document	Uploaded 2015-09-04	Repair queued
Complaints of Discrimination. 60 day FRN 08.28.2014.html	Supplementary Document	Uploaded 2015-09-04	Repair queued
NASA Complaints of Discrimination.Supporting Stmt.2015...doc	Supporting Statement A	Uploaded 2016-01-04	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
219495	NASA Form	Form	New

ICR Details

OMB Control No: 2700-0163	ICR Reference No: 201508-2700-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: NASA	Agency Tracking No:
Title: NASA Complaint of Discrimination Form 1355
Type of Information Collection: Existing collection in use without an OMB Control Number	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 01/11/2016
	Date Received in OIRA: 09/14/2015
Terms of Clearance: This collection is approved based on the revised materials provided by the Agency. NASA must report this collection as a violation in this year's information collection budget (ICB).

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2018	36 Months From Approved
Responses	60	0	0
Time Burden (Hours)	30	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: This information collection is necessary to ensure compliance with the Civil Rights Act of 1964, the Equal Opportunity Act of 1972, the Age Discrimination in Employment Act of 1972, and NASA policy. NASA strives to provide and maintain a work environment that is free of all forms of discrimination, including discriminatory harassment, as well as reprisal or retaliation for engaging in protected EEO activity. NASA also seeks to address harassing conduct at the earliest possible stage, before it becomes severe or persuasive. This information collection enables NASA to obtain information, in a structured manner, from non-federal employment applicants who believe they were discriminated against based on any of the following: race, color, religion, sex (to include sexual harassment, sex stereotyping, pregnancy, and gender identity), age, national origin, disability (mental and/or physical), genetic information (including family medical history), sexual orientation, reprisal, and class complaint.

---

Authorizing Statute(s): US Code: 29 USC CFR Name of Law: null
  

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 167	08/28/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 177	09/14/2015
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
NASA Form	1355P	NASA Complaint of Discrimination

---

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	60	0	0	60	0	0
Annual Time Burden (Hours)	30	0	0	30	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: The burden increase occurred because has established a single NASA form to enable individuals to formally report a complaint of discrimination. This form will be used by all NASA Centers.

---

Annual Cost to Federal Government: $21,299

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: 09/14/2015

---