EEO Complaint Forms

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form TD F 63-03.5 Formal Complaint Form	Form and Instruction	New	Available
Form TD F 62-03.10 Class Complaint	Form and Instruction	New	Available
Form TD F 32.03-9 Notice of Withdrawal from Participation in the EEO Pre-Complaint Process	Form and Instruction	New	Available
Form TD F 62-03.8 Notice of Right to FIle	Form and Instruction	New	Available
Form TD F 62.03.7 Notice of Rights and Responsabilities	Form and Instruction	New	Available
Form TD F 62-03.6 Agreement to Extend Counseling	Form and Instruction	New	Available
Form TD F 62-03.4 Agreement to Extend Counseling to Participate in Mediation	Form and Instruction	New	Available
Form TD F 62-03.2 Designation of Represenative	Form and Instruction	New	Available
Form TD F 62-03.1 EEO Informal Report of Counseling	Form and Instruction	New	Available
Form TD F 62-03.11 ADR Election Form	Form	New	Available
TAB 7 - Supporting Statement PT AB (Autosaved).doc	Supporting Statement A	Uploaded 2018-03-19	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
230736	Formal Complaint Form	Form and Instruction	New	Formal Complaint Form
230735	Class Complaint	Form and Instruction	New	Class Complaint
230734	Notice of Withdrawal from Participation in the EEO Pre-Complaint Process	Form and Instruction	New	Notice of Withdrawal from Participation in the EEO Pre-Complaint Process
230733	Notice of Right to FIle	Form and Instruction	New	Notice of Right to FIle
230732	Notice of Rights and Responsabilities	Form and Instruction	New	Notice of Rights and Responsabilities
230731	Agreement to Extend Counseling	Form and Instruction	New	Agreement to Extend Counseling
230730	Agreement to Extend Counseling to Participate in Mediation	Form and Instruction	New	Agreement to Extend Counseling to Participate in Mediation
230729	Designation of Represenative	Form and Instruction	New	Designation of Represenative
230728	EEO Informal Report of Counseling	Form and Instruction	New	EEO Informal Report of Counseling
230727	ADR Election Form	Form	New	ADR Election Form

ICR Details

OMB Control No: 1505-0262	ICR Reference No: 201705-1505-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: TREAS/DO	Agency Tracking No:
Title: EEO Complaint Forms
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 with change	Conclusion Date: 03/12/2019
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/26/2018
Terms of Clearance: Updated supporting statement during review.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2022	36 Months From Approved
Responses	90	0	0
Time Burden (Hours)	47	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: Treasury employees, former employees, and applicants for employment may contact the Department’s EEO Offices if they believe they have been subjected to discrimination based on race, color, sex (includes sexual harassment, sexual orientation and gender identity), national origin, religion, disability, age (40 or over), parental status, protected genetic information, or retaliation. A Treasury staff member responsible for obtaining information regarding the claim(s) of discrimination will record on a Report of Counseling (Intake) Form the aggrieved party’s (“the aggrieved”) personal information, i.e., name, address, telephone numbers, etc., as well as the bases and issues raised by the aggrieved. Thereafter, an EEO Counselor will be assigned, who will review the information on the Report of Counseling (Intake) Form and contact the aggrieved to schedule an initial interview. This interview may include, but is not limited to: verifying the information on the Intake Form, clearly defining the scope of the issues, reviewing the rights and responsibilities of the aggrieved and the agency during the EEO complaint process including the right to representation and anonymity, the applicable time frames, the option to extend the counseling process, the right to choose between Alternative Dispute Resolution (ADR) and EEO Counseling, and the overall stages of the complaint process.

---

Authorizing Statute(s): None

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 41464	08/31/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 12846	03/23/2018
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 10

table that charts list of burden

IC Title	Form No.	Form Name
ADR Election Form	TD F 62-03.11	ADR Election Form
Agreement to Extend Counseling	TD F 62-03.6	Agreement to Extend Counseling
Agreement to Extend Counseling to Participate in Mediation	TD F 62-03.4	Agreement to Extend Counseling to Participate in Mediation
Class Complaint	TD F 62-03.10	Class Complaint
Designation of Represenative	TD F 62-03.2	Designation of Represenative
EEO Informal Report of Counseling	TD F 62-03.1	EEO Informal Report of Counseling
Formal Complaint Form	TD F 63-03.5	Formal Complaint Form
Notice of Right to FIle	TD F 62-03.8	Notice of Right to FIle
Notice of Rights and Responsabilities	TD F 62.03.7	Notice of Rights and Responsabilities
Notice of Withdrawal from Participation in the EEO Pre-Complaint Process	TD F 32.03-9	Notice of Withdrawal from Participation in the EEO Pre-Complaint Process

---

ICR Summary of Burden

table that charts list 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	90	0	0	90	0	0
Annual Time Burden (Hours)	47	0	0	47	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 is a new collection

---

Annual Cost to Federal Government: $16,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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: 03/26/2018

---