Information Collection

DHS Civil Rights Compliance Form

IC 224608 under ICR 201801-1601-001 · OMB 1601-0024.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1601-0024 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DHS Form 3095 DHS Civil Rights Compliance Form	Form and Instruction
DHS Form 3095 DHS Civil Rights Compliance Form DHS Form 3095.pdf dhs.gov/resources-recipients-dhs-financial-assistance	Form and Instruction

IC Title:

DHS Civil Rights Compliance Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 6 CFR Part 21 44 CFR Part 7 (To search for a specific CFR, visit the Code of Federal Regulations.)

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 and Instruction	DHS Form 3095	DHS Civil Rights Compliance Form	DHS Form 3095.pdf	http://dhs.gov/resources-recipients-dhs-financial-assistance	Yes	Yes	Fillable Fileable

Line of Business: Homeland Security

Subfunction: Key Asset and Critical Infrastructure Protection

Privacy Act System of Records

Title: DHS/ALL-029

FR Citation: 75 FR 39266

Number of Respondents: 2,220

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	2,220	2,220
Annual IC Time Burden (Hours)	6,660	6,660
Annual IC Cost Burden (Dollars)	0	0

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.