VA Form 4939, Complaint of Employment Discrimination; VA Form 08-10192, Information for Pre-Complaint Processing

Forms and Documents

Document Name	Status
Form VA Form 08-10192 VA Form 08-10192, Information for Pre-Complaint Processing Form and Instruction	New
Form 4939 Complaint of Employment Discrimination Form and Instruction	Modified
OMB 2900-0176 supplementary.docx Supplementary Document	2016-03-25
White Paper for 2900-0716 Revision.docx Supplementary Document	2016-03-25
OMB Justification 2900-0716_12122016.docx Supporting Statement A	2016-12-13

IC Document Collections

IC ID	Document Title	Status
220758	VA Form 08-10192, Information for Pre-Complaint Processing Form and Instruction	New
186321	Complaint of Employment Discrimination Form and Instruction	Modified

ICR Details

OMB Control No: 2900-0716	ICR Reference No: 201603-2900-017
Status: Historical Active	Previous ICR Reference No: 201412-2900-008
Agency/Subagency: VA	Agency Tracking No: 2900-0716
Title: VA Form 4939, Complaint of Employment Discrimination; VA Form 08-10192, Information for Pre-Complaint Processing
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: 12/16/2016
	Date Received in OIRA: 07/18/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2019	36 Months From Approved	05/31/2018
Responses	1,022	0	315
Time Burden (Hours)	512	0	158
Cost Burden (Dollars)	0	0	0

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Abstract: VA Form 4939 is completed by VA employees, former employees and applicants for employment who wish to file a formal Equal Employment Opportunity complaint of discrimination. This Information Collection Request is being submitted as a revision to include VA Form 08-10192, Information for Pre-Complaint Processing. VA Form 08-10192 is the initial contact form filled out by individuals who believe they may have been discriminated against. An aggrieved person who believes he or she has been discriminated against on the basis of Race, Color, Religion, Sex, National Origin, Age, Disability, Genetic Information (including family medical history), and for participating in the EEO process or opposing unlawful discrimination.

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Authorizing Statute(s): None

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:
	81 FR 64	04/04/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 129	07/06/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Complaint of Employment Discrimination	4939	Complaint of Employment Discrimination
VA Form 08-10192, Information for Pre-Complaint Processing	VA Form 08-10192	Information for Pre-Complaint Processing

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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	1,022	315	0	707	0	0
Annual Time Burden (Hours)	512	158	0	354	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: This Information Collection Request is being submitted as a revision to include VA Form 08-10192, Information for Pre-Complaint Processing. VA Form 08-10192 is the initial contact form filled out by individuals who believe they may have been discriminated against. Inclusion of this form under the OMB approval number increases the overall burden by 707 respondents.

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Annual Cost to Federal Government: $36,756

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: 07/18/2016

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