Individuals or Households

Workplace Discrimination Complaints

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3060-1237 can be found here:

Documents and Forms

Document Name Document Type
Form FCC Form 5622 Individuals or Households Form
FCC Form 5622 FORMAL COMPLAINT OF DISCRIMINATION FCC FORMAL COMPLAINT FORM.pdf Form

Information Collection (IC) Details

IC Title:	Individuals or Households	Agency IC Tracking Number:	OWD

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 29 CFR 1614.105

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	FCC Form 5622	FORMAL COMPLAINT OF DISCRIMINATION	FCC FORMAL COMPLAINT FORM.pdf		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: 11	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	11	11
Annual IC Time Burden (Hours)	33	33
Annual IC Cost Burden (Dollars)	4,000	4,000

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.