USDA Program Discrimination Complaint Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Program Discrimination Complaint Form (Individuals)	Form	Modified	Missing upstream
Form AD 3027 Program Discrimination Complaint Form (State, Local and Tribal Government)	Form	Modified	Repair queued
Form AD 3027 Program Discrimination Complaint Form (Private Sector)	Form	Modified	Missing upstream
Program Complaint Form-FY24-Revision AD 3027 estimates.xlsx	Supplementary Document	Uploaded 2024-08-27	Missing upstream
Supporting Statement 2024 Program Complaint Form 0508-0002-8-27-24.docx	Supporting Statement A	Uploaded 2024-08-27	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
987	Program Discrimination Complaint Form (Individuals)	Form	Modified
198399	Program Discrimination Complaint Form (State, Local and Tribal Government)	Form	Modified
198398	Program Discrimination Complaint Form (Private Sector)	Form	Modified

ICR Details

OMB Control No: 0508-0002	ICR Reference No: 202408-0508-001
Status: Received in OIRA	Previous ICR Reference No: 202212-0508-001
Agency/Subagency: USDA/AgOCR	Agency Tracking No:
Title: USDA Program Discrimination Complaint Form
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  Yes
Type of Review Request: Regular	Date Submitted to OIRA: 08/29/2024

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	280	0
Time Burden (Hours)	280	0
Cost Burden (Dollars)	0	0

---

Abstract: The USDA needs the information from the complainant in order to respond to alleged discriminatory action.

---

Authorizing Statute(s): US Code: 29 USC 794 Name of Law: Rehabilitation, Comprehensive Services, and Developmental Disabilities Act of 1978.
   US Code: 5 USC 301
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 41927	05/14/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 70162	08/29/2024
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Program Discrimination Complaint Form (Individuals)	USDA Program Complaint Discrimination Form, AD 3027, N/A, USDA Program Complaint Discrimination Form	USDA Program Discrimination Complaint Form ,   Program Discrimination Complaint Form ,   AD 3027 Spanish ,   AD 3027 Spanish
Program Discrimination Complaint Form (Private Sector)	AD-3027-v7-July-31-2024-Draft_EN_Fillable_Remediat, AD-3027-v7-July-31-2024-Draft_ES_Fillable_Remediat, AD 3027, AD 3027	USDA Program Discrimination Complaint Form ,   Program Discrimination Complaint Form ,   USDA Program Compliant Form ,   USDA Program Compliant Form
Program Discrimination Complaint Form (State, Local and Tribal Government)	AD-3027 ES Fillable Remediated, AD-3027-v7-July-31-2024-Draft_EN_Fillable_Remediat, AD 3027, AD 3027	USDA Program Discrimination Complaint Form ,   Program Discrimination Complaint Form ,   USDA Program Compliant Form ,   USDA Program Compliant Form

---

ICR Summary of Burden

table that charts list of burden

	Total Request	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	280	0	0	2	0	278
Annual Time Burden (Hours)	280	0	0	2	0	278
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a reinstatement with change of a previously approved collection for which approval has expired. There is a change in the number of respondents estimated in 2021. The agency is requesting an estimated 280 total annual burden hours. The number of total annual respondents cited in this supporting statement shows an increase by 2 from 278 respondents in 2022 to a projected 280 respondents. The methodology includes an average of program complaint participants over the three-year period from 2020, 2021 and 2022. This increase in respondents and is a modification that is not the result of deliberate federal government action uncontrollable not due to no direct action from the Federal government action.

---

Annual Cost to Federal Government: $4,284

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

---

Common Form ICR:  Yes

Description/Changes for Common Form Usage:  The USDA needs the information from the complainant in order to respond to alleged discriminatory action.

Approved RCFs using this ICR

table that charts list of RCF

Agency/Sub Agency	RCF ID	RCF Title	RCF Status	IC Title

---

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: 08/29/2024

---