Information Collection

Alternative Dispute Resolution Form Requests, FCC Form 5628

IC 232542 under ICR 201808-3060-002 · OMB 3060-1258.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3060-1258 can be found here:

Documents and Forms

Document Name Document Type
Form Alternate Dispute Alternative Dispute Resolution Form Requests, FCC Form 5628 Form
Alternate Dispute FCC Form 5628 ADR Intake Form (final).docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Alternative Dispute Resolution Form Requests, FCC Form 5628	Agency IC Tracking Number:	OWD

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 29 CFR 1614.108(b) 29 CFR 1614.603 29 CFR 1614.102 (b)(2) 29 CFR 1614.105(f)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	Alternate Dispute Resolution Intake Form	FCC Form 5628	ADR Intake Form (final).docx		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: 5	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5	5
Annual IC Time Burden (Hours)	18	18
Annual IC Cost Burden (Dollars)	3,750	3,750

Documents for IC

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.