Individual Complaint of Employment Discrimination

Forms and Documents

Document Name	Status
Form DOT F 1050–8 Individual Complaint of Employment Discrimination Form and Instruction	Modified
2105-0556_EEO_30-day_81.FR.85685_11.28.2016.pdf Supplementary Document	2016-12-02
EEO_2105-0556_60_Day_81.Fr.63855_09.16.2016.pdf Supplementary Document	2016-12-02
2105-0556 EEO Complaint Form Supporting Statement 11.16.16.doc Supporting Statement A	2016-12-02
GINA.pdf Supplementary Document	2012-10-24
29 CFR Part 1614.pdf Supplementary Document	2009-07-31

IC Document Collections

IC ID	Document Title	Status
44070	Individual Complaint of Employment Discrimination Form and Instruction	Modified

ICR Details

OMB Control No: 2105-0556	ICR Reference No: 201612-2105-001
Status: Historical Active	Previous ICR Reference No: 201508-2105-002
Agency/Subagency: DOT/OST	Agency Tracking No:
Title: Individual Complaint of Employment Discrimination
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/24/2017
	Date Received in OIRA: 12/20/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2020	36 Months From Approved	01/31/2017
Responses	10	0	10
Time Burden (Hours)	30	0	30
Cost Burden (Dollars)	58	0	58

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Abstract: The DOT will utilize the form to collect information necessary to process Equal Employment Opportunity (EEO) discrimination complaints filed by employees, former employees, and applicants for employment with the Department. These complaints are processed in accordance with the Equal Employment Opportunity Commission’s regulations, 29 CFR part 1614, as amended. The DOT will use the form to: (a) request requisite information from the individual for processing his or her EEO employment discrimination complaint; and (b) obtain information to identify an individual or his or her attorney or other representative, if appropriate.

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Authorizing Statute(s): US Code: 42 USC 2000ff Name of Law: PROHIBITING EMPLOYMENT DISCRIMINATION ON THE BASIS OF GENETIC INFORMATION
   PL: Pub.L. 110 - 233 122 STAT. 881 Name of Law: Genetic Information Nondiscrimination Act of 2008.
  

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 63855	09/16/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 85685	11/28/2016
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Individual Complaint of Employment Discrimination	DOT F 1050–8	Individual Complaint of Employment

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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	10	10	0	0	0	0
Annual Time Burden (Hours)	30	30	0	0	0	0
Annual Cost Burden (Dollars)	58	58	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $2,590,550

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: 12/20/2016

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