Information Collection

DHS Civil Rights and Civil Liberties Complaint and Privacy Waiver Form

IC 247887 under ICR 202212-1601-001 · OMB 1601-0035.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
DHS_CRCL_Civil Rights Complaint Form_8-1-22.pdf www.dhs.gov/file-civil-rights-complaint	Other-website
DHS_CRCL_Civil Rights Complaint Form_8-1-22.pdf www.dhs.gov/file-civil-rights-complaint	Other-website
PRA Screenshots for Web Portal.docx	Other-screenshots
PRA Screenshots for Web Portal.docx	Other-screenshots

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

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
Other-website			DHS_CRCL_Civil Rights Complaint Form_8-1-22.pdf	https://www.dhs.gov/file-civil-rights-complaint	Yes	No	Fillable Printable
Other-screenshots			PRA Screenshots for Web Portal.docx		Yes	Yes	Fillable Fileable Signable

Line of Business: Workforce Management

Subfunction: Labor Rights Management

Privacy Act System of Records

Title: DHS ALL-029 Civil Rights and Civil Liberties Records System of Records

FR Citation: 86 FR 33331

Number of Respondents: 2,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	2,000	2,000
Annual IC Time Burden (Hours)	2,000	2,000
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.