NASA Complaint of Discrimination Form 1355

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1355P NASA Form	Form	Unchanged	Available
FRN 2700-0163 30_day0501118.pdf	Supplementary Document	Uploaded 2018-06-15	Available
FRN 2700-0163 60_day0222118.pdf	Supplementary Document	Uploaded 2018-06-15	Available
NASA Complaints of Discrimination.Supporting Stmt.2015..doc	Supporting Statement A	Uploaded 2018-06-15	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
219495	NASA Form	Form	Unchanged

ICR Details

OMB Control No: 2700-0163	ICR Reference No: 201806-2700-002
Status: Active	Previous ICR Reference No: 201508-2700-003
Agency/Subagency: NASA	Agency Tracking No:
Title: NASA Complaint of Discrimination Form 1355
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/16/2018
	Date Received in OIRA: 06/15/2018
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2021	36 Months From Approved	07/31/2018
Responses	60	0	60
Time Burden (Hours)	30	0	30
Cost Burden (Dollars)	0	0	0

---

Abstract: This information collection is necessary to ensure compliance with the Civil Rights Act of 1964, the Equal Opportunity Act of 1972, the Age Discrimination in Employment Act of 1972, and NASA policy. NASA strives to provide and maintain a work environment that is free of all forms of discrimination, including discriminatory harassment, as well as reprisal or retaliation for engaging in protected EEO activity. NASA also seeks to address harassing conduct at the earliest possible stage, before it becomes severe or persuasive. This information collection enables NASA to obtain information, in a structured manner, from non-federal employment applicants who believe they were discriminated against based on any of the following: race, color, religion, sex (to include sexual harassment, sex stereotyping, pregnancy, and gender identity), age, national origin, disability (mental and/or physical), genetic information (including family medical history), sexual orientation, reprisal, and class complaint. Pursuant to MD-715, EEO Reporting Requirements for Federal Agencies, it is also NASA policy to promote the full realization of a model EEO program by effectively considering and addressing concerns that arise under Title VII and Section 501 of the Rehabilitation Act. NASA's efforts to be a model Agency for EEO include identification of and strategies to remove deficiencies in EEO programs and barriers to EEO in any aspect of Agency policies, programs, or practices including, but not limited to, outreach and recruiting, hiring, promoting, training, awareness, and facilities and program accessibility for employees of NASA. Model EEO efforts include monitoring strategies and employment practices in the areas of hiring, transfers, reassignments, promotions, awards, benefits, and separations. These efforts are undertaken to help gain and maintain a talented NASA workforce that is reflective of the Nation's demographic diversity. This information collection also supports NASA’s self-assessment processes in that regard.

---

Authorizing Statute(s): US Code: 29 USC CFR Name of Law: Delegation of Authority to Act in Manners Pertaining to Discrimination Complaints
  

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:
	83 FR 7497	02/21/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 19117	05/01/2018
Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

IC Title	Form No.	Form Name
NASA Form	1355P	NASA Complaint of Discrimination

---

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	60	60	0	0	0	0
Annual Time Burden (Hours)	30	30	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $25,643

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: 06/15/2018

---