Information Collection

Discrimination Complaint Form

IC 217700 under ICR 201512-1405-002 · OMB 1405-0220.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1405-0220 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DS4282 Discrimination Complaint Form	Form and Instruction
DS4282 Discrimination Complaint Form DS4282 12-7-2015.pdf	Form and Instruction

IC Title:

Discrimination Complaint Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

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	DS4282	Discrimination Complaint Form	DS4282 12-7-2015.pdf		No		Fillable Fileable

Line of Business: Litigation and Judicial Activities

Subfunction: Legal Investigation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	10	10
Annual IC Time Burden (Hours)	10	10
Annual IC Cost Burden (Dollars)	10	10

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.