Federal Government

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⚠️ Notice: This information collection may be referencing outdated material.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 5621 Federal Government Form
FCC Form 5621 INFORMAL COMPLAINT of DISCRIMINATION EEO Form 5621 - Informal Complaint.pdf Form

Information Collection (IC) Details

IC Title:	Federal Government	Agency IC Tracking Number:	OWD

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 29 CFR 1614.106

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	FCC Form 5621	INFORMAL COMPLAINT of DISCRIMINATION	EEO Form 5621 - Informal Complaint.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: 12	Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	12	12
Annual IC Time Burden (Hours)	34	34
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.