DHS Individual Complaint of Employment Discrimination

Forms and Documents

Document Name	Status
Form DHS Form 3090-1 DHS Individual Complaint of Employment Discrimination Form and Instruction	Modified
1610-0001 - Supporting Statement A - DHS Individual Complaint of Employm.ent FINAL 2021.docx Supporting Statement A	2021-08-02
2021-16394.pdf Supplementary Document	2021-08-02
2021-10712 (3).pdf Supplementary Document	2021-08-02
29 USC 206.pdf Supplementary Document	2015-04-09
Executive Order 11478.docx Supplementary Document	2015-04-09
42 USC 2000ff.pdf Supplementary Document	2015-04-09
42 USC 2000e.pdf Supplementary Document	2015-04-09
29 USC 791.pdf Supplementary Document	2015-04-09
29 USC 621.pdf Supplementary Document	2015-04-09
EEO Director 462 MEMORANDUM April 2011.pdf Supplementary Document	2011-06-30
PART 1614--FEDERAL SECTOR EQUAL EMPLOYMENT OPPORTUNITY.pdf Supplementary Document	2008-03-31

IC Document Collections

IC ID	Document Title	Status
20218	DHS Individual Complaint of Employment Discrimination Form and Instruction	Modified

ICR Details

OMB Control No: 1610-0001	ICR Reference No: 202103-1610-001
Status: Received in OIRA	Previous ICR Reference No: 201504-1610-001
Agency/Subagency: DHS/OCR	Agency Tracking No:
Title: DHS Individual Complaint of Employment Discrimination
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 08/02/2021

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	136	0
Time Burden (Hours)	68	0
Cost Burden (Dollars)	0	0

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Abstract: This form provides information necessary for processing formal complaints of employment discrimination in accordance with EEOC Management Directive (EEO-MD) 110, and 29 C.F.R. part 1614.

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Authorizing Statute(s): US Code: 42 USC 2000e Name of Law: Title VII of the Civil Rights Act
   US Code: 29 USC 621 Name of Law: Age Discrimination in Employment Act
   US Code: 29 USC 791 Name of Law: Rehabilitation Act
   US Code: 22 USC 206 Name of Law: Equal Pay Act
   EO: EO 11478 Name/Subject of EO: Equal employment opportunity in the Federal Government
   US Code: 42 USC 2000ff Name of Law: Genetic Information Nondiscrimination Act (GINA)
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 27642	05/21/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 41505	08/02/2021
Did the Agency receive public comments on this ICR? Yes

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

IC Title	Form No.	Form Name
DHS Individual Complaint of Employment Discrimination	DHS Form 3090-1	DHS Individual Compliant of Employment Discrimination

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ICR Summary of Burden

	Total Request	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	136	0	0	0	-1,064	1,200
Annual Time Burden (Hours)	68	0	0	0	-532	600
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: There is a decrease in burden. The previous approval documentation mistakenly included the burden for Federal Employees. This error has been corrected, resulting in the reporting of a reduced burden.

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Annual Cost to Federal Government: $34,878

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? No

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Common Form ICR:  No

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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: 08/02/2021

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