DHS Individual Complaint of Employment Discrimination

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form DHS Form 3090-3 DHS Individual Compliant of Employment Discrimination	Form and Instruction	Modified	Available
Form DHS Form 3090-3 DHS Individual Complaint of Employment Discrimination	Form and Instruction	Modified	Repair queued
DHS Form 3090 (01.25.2022) (003).pdf	Supplementary Document	Uploaded 2023-06-21	Repair queued
30_Day_FRN_DHS-2023-0013-0002.pdf	Supplementary Document	Uploaded 2023-06-30	Repair queued
60_Day_FRN_DHS-2023-0013 (3).pdf	Supplementary Document	Uploaded 2023-06-30	Repair queued
1610-0001 - Supporting Statement A - DHS Individual Complaint of Employment - CRCL updates Jan2023 (1).docx	Supporting Statement A	Uploaded 2023-06-30	Repair queued
29 USC 206.pdf	Supplementary Document	Uploaded 2015-04-09	Repair queued
Executive Order 11478.docx	Supplementary Document	Uploaded 2015-04-09	Repair queued
42 USC 2000ff.pdf	Supplementary Document	Uploaded 2015-04-09	Repair queued
42 USC 2000e.pdf	Supplementary Document	Uploaded 2015-04-09	Repair queued
29 USC 791.pdf	Supplementary Document	Uploaded 2015-04-09	Available
29 USC 621.pdf	Supplementary Document	Uploaded 2015-04-09	Repair queued
EEO Director 462 MEMORANDUM April 2011.pdf	Supplementary Document	Uploaded 2011-06-30	Repair queued
PART 1614--FEDERAL SECTOR EQUAL EMPLOYMENT OPPORTUNITY.pdf	Supplementary Document	Uploaded 2008-03-31	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
20218	DHS Individual Complaint of Employment Discrimination	Form and Instruction	Modified	DHS Individual Compliant of Employment Discrimination
20218	DHS Individual Complaint of Employment Discrimination	Form and Instruction	Modified

ICR Details

OMB Control No: 1610-0001	ICR Reference No: 202306-1610-001
Status: Active	Previous ICR Reference No: 202103-1610-001
Agency/Subagency: DHS/OCR	Agency Tracking No:
Title: DHS Individual Complaint of Employment Discrimination
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/16/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/30/2023
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2027	36 Months From Approved	04/30/2024
Responses	136	0	136
Time Burden (Hours)	68	0	68
Cost Burden (Dollars)	0	0	0

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Abstract: This form provides information necessary for processing formal complaints of employment discrimination in accordance with EEOC Management Directive (EEO-MD) 110, and 29 C.F.R. part 1614.

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Authorizing Statute(s): US Code: 42 USC 2000e Name of Law: Title VII of the Civil Rights Act
   US Code: 29 USC 621 Name of Law: Age Discrimination in Employment Act
   US Code: 29 USC 791 Name of Law: Rehabilitation Act
   US Code: 22 USC 206 Name of Law: Equal Pay Act
   EO: EO 11478 Name/Subject of EO: Equal employment opportunity in the Federal Government
   US Code: 42 USC 2000ff Name of Law: Genetic Information Nondiscrimination Act (GINA)
  

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:
	88 FR 16999	03/21/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 39447	06/16/2023
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 Individual Complaint of Employment Discrimination	DHS Form 3090-3	DHS Individual Compliant of Employment Discrimination

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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	136	136	0	0	0	0
Annual Time Burden (Hours)	68	68	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:

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Annual Cost to Federal Government: $34,878

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

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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: 06/30/2023

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