Information Collection

Workplace Discrimination Complaints

IC 226756 under ICR 201704-3060-028 · OMB 3060-1237.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3060-1237 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form FCC 5621 Workplace Discrimination Complaints	Form
FCC 5621 Pre-Complaint Form for Discrimination Pre-Complaint Form Final OMB.pdf	Form
FCC 5622 Formal Complaint for Discrimination Formal Complaint Final OMB.pdf	Form

IC Title:

Workplace Discrimination Complaints

Agency IC Tracking Number:

OWD

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 29 CFR 1614.105 29 CFR 1614.106

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	FCC 5621	Pre-Complaint Form for Discrimination	Pre-Complaint Form Final OMB.pdf		Yes	Yes	Fillable Fileable Signable
Form	FCC 5622	Formal Complaint for Discrimination	Formal Complaint Final OMB.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: General Government

Subfunction: Central Fiscal Operations

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 26

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	26	26
Annual IC Time Burden (Hours)	91	91
Annual IC Cost Burden (Dollars)	15,000	15,000

Documents for IC

table that charts IC Documents
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.