USDA Program Discrimination Complaint Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form AD 3027 Program Discrimination Complaint Form	Form	Modified	Available
USDA Program Discrimination Complaint Form	Form	Modified	Available
Program Discrimination Complaint Form (Individuals)	Form	Modified	Repair queued
Form AD 3027 Program Discrimination Complaint Form	Form	Modified	Available
USDA Program Discrimination Complaint Form	Form	Modified	Available
Program Discrimination Complaint Form (State, Local and Tribal Government)	Form	Modified	Repair queued
Form AD 3027 Program Discrimination Complaint Form	Form	Modified	Available
USDA Program Discrimination Complaint Form	Form	Modified	Available
Program Discrimination Complaint Form (Private Sector)	Form	Modified	Repair queued
0508-0002 - Change Justification for Spanish version.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2022-12-07	Available
0508-0002 - Change Justification for Spanish version.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2022-12-07	Repair queued
OMB 0508-0002 - language changes_4262022 (FINAL) 10.04.22.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2022-10-04	Available
OMB 0508-0002 - language changes_4262022 (FINAL) 10.04.22.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2022-10-04	Repair queued
Supporting Statement 2021 Program Complaint Form 0508-0002.docx	Supporting Statement A	Uploaded 2021-02-25	Available
Supporting Statement 2021 Program Complaint Form 0508-0002.docx	Supporting Statement A	Uploaded 2021-02-25	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
987	Program Discrimination Complaint Form (Individuals)	Form	Modified	Program Discrimination Complaint Form
987	Program Discrimination Complaint Form (Individuals)	Form	Modified	USDA Program Discrimination Complaint Form
987	Program Discrimination Complaint Form (Individuals)	Form	Modified
198399	Program Discrimination Complaint Form (State, Local and Tribal Government)	Form	Modified	Program Discrimination Complaint Form
198399	Program Discrimination Complaint Form (State, Local and Tribal Government)	Form	Modified	USDA Program Discrimination Complaint Form
198399	Program Discrimination Complaint Form (State, Local and Tribal Government)	Form	Modified
198398	Program Discrimination Complaint Form (Private Sector)	Form	Modified	Program Discrimination Complaint Form
198398	Program Discrimination Complaint Form (Private Sector)	Form	Modified	USDA Program Discrimination Complaint Form
198398	Program Discrimination Complaint Form (Private Sector)	Form	Modified

ICR Details

OMB Control No: 0508-0002	ICR Reference No: 202212-0508-001
Status: Historical Active	Previous ICR Reference No: 202210-0508-001
Agency/Subagency: USDA/AgOCR	Agency Tracking No:
Title: USDA Program Discrimination Complaint Form
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/14/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/07/2022
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2024	05/31/2024	05/31/2024
Responses	278	0	278
Time Burden (Hours)	278	0	278
Cost Burden (Dollars)	0	0	0

---

Abstract: The USDA needs the information from the complainant in order to respond to alleged discriminatory action.

---

Authorizing Statute(s): US Code: 29 USC 794
   US Code: 5 USC 301
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 75283	11/25/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 11495	02/25/2021
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Program Discrimination Complaint Form (Individuals)	AD 3027, N/A	USDA Program Discrimination Complaint Form ,   Program Discrimination Complaint Form
Program Discrimination Complaint Form (Private Sector)	N/A, AD 3027	USDA Program Discrimination Complaint Form ,   Program Discrimination Complaint Form
Program Discrimination Complaint Form (State, Local and Tribal Government)	N/A, AD 3027	USDA Program Discrimination Complaint Form ,   Program Discrimination Complaint Form

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	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	278	278	0	0	0	0
Annual Time Burden (Hours)	278	278	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a revision of a currently approved information collection. There is a change in the number of respondents estimated in 2017. The number cited in this supporting statement shows an increase from 141 respondents in 2017 to a projected 278 respondents. The methodology includes an average of program complaint participants over the five-year period from 2014, 2015, 2016, 2018 and 2019. The increase in the number participants is based on the use of actual data. The increase of costs is directly associated with the increase costs of the federal salary cost and the increase of program participation.

---

Annual Cost to Federal Government: $3,670

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

---

Common Form ICR:  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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 12/07/2022

---