Complaint of Discrimination Under Section 504, Section 508 or Title VI

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form DS4282 Discrimination Complaint Form	Form and Instruction	Modified	Available
1405-0220Legal Authorities 12-07.docx	Supplementary Document	Uploaded 2016-03-24	Available
1405-0220 DS-4282 Supporting Statement Final Rule.docx	Supporting Statement A	Uploaded 2016-03-24	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
217700	Discrimination Complaint Form	Form and Instruction	Modified

ICR Details

OMB Control No: 1405-0220	ICR Reference No: 201603-1405-005
Status: Historical Active	Previous ICR Reference No: 201512-1405-002
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Complaint of Discrimination Under Section 504, Section 508 or Title VI
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 05/25/2016
	Date Received in OIRA: 03/24/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2019	36 Months From Approved
Responses	10	0	0
Time Burden (Hours)	10	0	0
Cost Burden (Dollars)	10	0	0

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Abstract: The DS-4282 will be used to submit complaints of discrimination under Title VI of the Civil Rights Act of 1964; and Sections 504 and 508 of the Rehabilitation Act of 1973.

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Authorizing Statute(s): US Code: 42 USC 2000 Name of Law: Title VI of the Civil Rights Act of 1964
   US Code: 29 USC 794 Name of Law: Rehabilitation Act of 1973
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
1400-AD87	Final or interim final rulemaking	81 FR 32645	05/24/2016

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 44	01/04/2016
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Discrimination Complaint Form	DS4282	Discrimination Complaint Form

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ICR Summary of Burden

table that charts list 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	10	0	0	10	0	0
Annual Time Burden (Hours)	10	0	0	10	0	0
Annual Cost Burden (Dollars)	10	0	0	10	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: This is a new collection.

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Annual Cost to Federal Government: $1,602

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: 03/24/2016

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