Information Collection

DHS Civil Rights Evaluation Tool

IC 224608 under ICR 202406-1601-001 · OMB 1601-0024.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
1601—0024 DHS Civil Rights Evaluation Tool.pptx dhs.gov/resources-recipients-dhs-financial-assistance	Other-Screenshots of portal
1601—0024 DHS Civil Rights Evaluation Tool.pptx dhs.gov/resources-recipients-dhs-financial-assistance	Other-Screenshots of portal
DHS Form 3095 Civil Rights Evaluation Tool DHS Form 3095 Civil Rights Evaluation Tool 508 Accessible with UEI.pdf	Form and Instruction
DHS Form 3095 Civil Rights Evaluation Tool DHS Form 3095 Civil Rights Evaluation Tool 508 Accessible with UEI.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 6 CFR Parts 17, 19, 21 44 CFR Parts 7, 19 (To search for a specific CFR, visit the Code of Federal Regulations.)

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-Screenshots of portal			1601â0024 DHS Civil Rights Evaluation Tool.pptx	http://dhs.gov/resources-recipients-dhs-financial-assistance	Yes	Yes	Fillable Fileable
Form and Instruction	DHS Form 3095	Civil Rights Evaluation Tool	DHS Form 3095 Civil Rights Evaluation Tool 508 Accessible with UEI.pdf		Yes	Yes	Fillable Fileable

Line of Business: Homeland Security

Subfunction: Key Asset and Critical Infrastructure Protection

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	3,350	1,388	1,962
Annual IC Time Burden (Hours)	10,050	4,164	5,886
Annual IC Cost Burden (Dollars)	0	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.