Workplace Discrimination Complaints

Forms and Documents

Document Name	Status
Form FCC 5621 Workplace Discrimination Complaints Form	New
OWD_ New Collection_Workplace Discrimation Complaints (final).docx Supporting Statement A	2017-05-10

IC Document Collections

IC ID	Document Title	Status
226756	Workplace Discrimination Complaints Form	New

ICR Details

OMB Control No: 3060-1237	ICR Reference No: 201704-3060-028
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: FCC	Agency Tracking No: OWD
Title: Workplace Discrimination Complaints
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 without change	Conclusion Date: 06/28/2017
	Date Received in OIRA: 05/10/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2020	36 Months From Approved
Responses	26	0	0
Time Burden (Hours)	91	0	0
Cost Burden (Dollars)	15,000	0	0

---

Abstract: FCC employees, former employees and applicants for employment who believe they were denied equal employment opportunity based on race, color, religion, gender, national origin, age, physical or mental disability, genetic information and/or reprisal will complete FCC-5621 and FCC-5622.

---

Authorizing Statute(s): US Code: 42 USC 2000e-16 Name of Law: null
   US Code: 42 USC 2000ff-6(f) Name of Law: null
   US Code: 29 USC 206(d) Name of Law: null
   US Code: 29 USC 6333a Name of Law: null
   US Code: 29 USC 791 Name of Law: null
   US Code: 29 USC 794a Name of Law: null
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 12094	02/28/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 21815	05/10/2017
Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
Workplace Discrimination Complaints	FCC 5621, FCC 5622	Pre-Complaint Form for Discrimination ,   Formal Complaint for Discrimination

---

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	26	0	0	26	0	0
Annual Time Burden (Hours)	91	0	0	91	0	0
Annual Cost Burden (Dollars)	15,000	0	0	15,000	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Changing Regulations

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

Burden Reduction Due to:

Short Statement: This is a new information collection request resulting in a program change/increase to the total respondents of 26, total annual responses of 26 and total annual burden hours of 91 hours. These estimates will be added to OMB’s Active Inventory.

---

Annual Cost to Federal Government: $251,270

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

---

Common Form ICR:  No

---

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: 05/10/2017

---