DHS Individual Complaint of Employment Discrimination

ICR 202103-1610-001

OMB: 1610-0001

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supporting Statement A
2021-08-02
Supplementary Document
2021-08-02
Supplementary Document
2021-08-02
Supplementary Document
2015-04-09
Supplementary Document
2015-04-09
Supplementary Document
2015-04-09
Supplementary Document
2015-04-09
Supplementary Document
2015-04-09
Supplementary Document
2015-04-09
Supplementary Document
2011-06-30
Supplementary Document
2008-03-31
IC Document Collections
ICR Details
1610-0001 202103-1610-001
Received in OIRA 201504-1610-001
DHS/OCR
DHS Individual Complaint of Employment Discrimination
Reinstatement without change of a previously approved collection   No
Regular 08/02/2021
  Requested Previously Approved
36 Months From Approved
136 0
68 0
0 0

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.

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)
  
None

Not associated with rulemaking

  86 FR 27642 05/21/2021
86 FR 41505 08/02/2021
Yes

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

  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
No
No
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.

$34,878
No
    Yes
    Yes
No
No
No
No
Tyrone Huff 202 447-0106 [email protected]

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
08/02/2021


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