Information Collection

Program Discrimination Complaint Form (Individuals)

IC 987 under ICR 202210-0508-001 · OMB 0508-0002.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0508-0002 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Program Discrimination Complaint Form (Individuals)	Form
USDA Program Discrimination Complaint Form AD3027 Program Discrimination Complaint From (proposed form) 10.04.22.pdf	Form
USDA Program Discrimination Complaint Form AD3027 Program Discrimination Complaint From (proposed form) 10.04.22.pdf	Form

IC Title:

Program Discrimination Complaint Form (Individuals)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 7 CFR 15.6

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	N/A	USDA Program Discrimination Complaint Form	AD3027 Program Discrimination Complaint From (proposed form) 10.04.22.pdf		Yes	No	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records

Title: USDA/OASCR-1, Civil Rights Enterprise System, (CRES)

FR Citation: 83 FR 65135

Number of Respondents: 158

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	158	158
Annual IC Time Burden (Hours)	158	158
Annual IC Cost Burden (Dollars)	0	0

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.