Complaint of Employment Discrimination

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

Documents and Forms

Document Name Document Type
Form 4939 Complaint of Employment Discrimination Form and Instruction
4939 Complaint of Employment Discrimination VA Form 4939 01 26 2017 wEdit.pdf vaww.va.gov/vaforms Form and Instruction

Information Collection (IC) Details

IC Title:	Complaint of Employment Discrimination	Agency IC Tracking Number:	2900-0716

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 29 CFR 1614.106

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	4939	Complaint of Employment Discrimination	VA Form 4939 01 26 2017 wEdit.pdf	http://vaww.va.gov/vaforms	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Legislative Functions

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 315	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	315	315
Annual IC Time Burden (Hours)	158	158
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.