Federal Government

Alternative Dispute Resolution Form Requests, FCC Form 5628

Documents and Forms

Document Name Document Type
Form Alternate Dispute Federal Government Form
Alternate Dispute FCC Form 5628 ADR Intake Form (final)_owd updated 06172024.docx 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 1614.102 (b)(2) 29 CFR 1614.105(f) 29 CFR 1614.108(b)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	Alternate Dispute Resolution Intake Form	FCC Form 5628	ADR Intake Form (final)_owd updated 06172024.docx		Yes	Yes	Fillable Fileable Signable

Line of Business: General Government

Subfunction: Central Fiscal Operations

Privacy Act System of Records
Title: EEOC/GOVT1, EEO Fed. GOVT Complaint & Appeals Records	FR Citation: 81 FR 81116

Number of Respondents: 2	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2	-5	7
Annual IC Time Burden (Hours)	6	-19	25
Annual IC Cost Burden (Dollars)	1,875	-8,125	10,000

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.