Information Collection

Alternative Dispute Resolution Form Requests, FCC Form 5628

IC 232542 under ICR 202107-3060-005 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

IC Title:

Alternative Dispute Resolution Form Requests, FCC Form 5628

Agency IC Tracking Number:

OWD

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

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

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	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: FCC/OWD-2, Alternative Dispute Resolution (ADR) Program

FR Citation: 84 FR 14374

Number of Respondents: 7

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	7	2	5
Annual IC Time Burden (Hours)	25	7	18
Annual IC Cost Burden (Dollars)	10,000	6,250	3,750

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.