DHS Civil Rights Compliance Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form DHS Form 3095 DHS Civil Rights Compliance Form	Form and Instruction	Modified	Available
OMB Form 83-C for DHS Form 3095.pdf	Justification for No Material/Nonsubstantive Change	Uploaded 2023-01-11	Available
1601-0024_Supporting Statement A for Renewal DHS Form 3095.docx	Supporting Statement A	Uploaded 2023-01-11	Available
Narrative of Changes Table - DHS Civil Rights Evaluation Tool Updated 2.16.2021.docx	Supplementary Document	Uploaded 2023-01-11	Available
42 USC 6101.pdf	Supplementary Document	Uploaded 2016-11-28	Available
42 USC 2000d-1.pdf	Supplementary Document	Uploaded 2016-11-28	Available
29 USC 794.pdf	Supplementary Document	Uploaded 2016-11-28	Available
28 CFR Part 42.docx	Supplementary Document	Uploaded 2016-11-28	Available
20 USC 1681.pdf	Supplementary Document	Uploaded 2016-11-28	Available
44 CFR Part 19.pdf	Supplementary Document	Uploaded 2016-11-28	Available
44 CFR Part 7.pdf	Supplementary Document	Uploaded 2016-11-28	Available
6 CFR Part 21.pdf	Supplementary Document	Uploaded 2016-11-28	Available
6 CFR Part 17.pdf	Supplementary Document	Uploaded 2016-11-28	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
224608	DHS Civil Rights Compliance Form 3095	Form and Instruction	Modified	DHS Civil Rights Compliance Form

ICR Details

OMB Control No: 1601-0024	ICR Reference No: 202301-1601-001
Status: Historical Active	Previous ICR Reference No: 202103-1601-002
Agency/Subagency: DHS/OS	Agency Tracking No:
Title: DHS Civil Rights Compliance 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: 01/11/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/11/2023
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2024	08/31/2024	08/31/2024
Responses	1,962	0	1,962
Time Burden (Hours)	5,886	0	5,886
Cost Burden (Dollars)	0	0	0

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Abstract: DHS has an obligation to enforce nondiscrimination requirements to ensure that its federally assisted programs and activities are administered in a nondiscriminatory manner. In order to carry out its enforcement responsibilities, DHS must obtain a signed assurance of compliance and collect and review information from recipients to ascertain their compliance with applicable requirements. DHS implementing regulations and the Department of Justice (DOJ) regulation Coordination of Non-discrimination in Federally Assisted Program, 28 C.F.R. Part 42, provide for the collection of data and information from recipients (see 28 C.F.R. 42.406). DHS uses DHS Form 3095: DHS Civil Rights Evaluation Tool as the primary tool to implement this information collection. The purpose of the information collection is to advise recipients of their civil rights obligations; obtain an assurance of compliance from each recipient, and collect pertinent civil rights information to ascertain if the recipient has in place adequate policies and procedures to achieve compliance, and to determine what, if any, further action may be needed to ensure the recipient is in compliance and will carry out its programs and activities in a nondiscriminatory manner.

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Authorizing Statute(s): US Code: 29 USC 794 Name of Law: Section 504 of the Rehabilitation Act of 1973
   US Code: 42 USC 6101 Name of Law: Age Discrimination Act of 1975
   US Code: 20 USC 1681 Name of Law: Title IX of the Education Amendments of 1972
   US Code: 42 USC 2000d-1 Name of Law: Civil Rights Act of 1964
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 73731	11/19/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 12492	03/03/2021
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
DHS Civil Rights Compliance Form 3095	DHS Form 3095	DHS Civil Rights Compliance Form

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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	1,962	1,962	0	0	0	0
Annual Time Burden (Hours)	5,886	5,886	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: DHS is not proposing any changes to the information collected in the form but is proposing changes to Section 1 of the form's instructions and Section 2 of the form to streamline and clarify the process for submitting the completed form. The form's changes to Section 1 and 2 do not impact the burden analysis. The burden has decreased from the previous reporting period (from 3331 to 2929 total respondents, or 2220 to 1962 annualized number of responses). Additionally, to clearly present information on annualized burden, DHS adjusted the method for calculating burden. DHS calculated burden based on the total number of respondents (2929) and annualized the number of responses per respondent (.67), whereas in the previous reporting period DHS calculated burden based on the number of responses (2220) assuming 1 response annually per respondent. These different calculation methods produce the same results but present the information differently.

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Annual Cost to Federal Government: $229,797

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.     No

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.     No

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

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Common Form ICR:  No

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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: 01/11/2023

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