USDA Program Discrimination Complaint Form

Forms and Documents

Document Name	Status
Form AD 3027 FRA Program Discrimination Complaint Form (Individuals) Form and Instruction	Modified
Form AD 3027 Program Discrimination Complaint Form (State, Local and Tribal Government) Form	Unchanged
Form AD 3027 Program Discrimination Complaint Form (Private Sector) Form	Unchanged
Change Request Memo Justification-Ver4A OCIO passback 11-29-24.docx Justification for No Material/Nonsubstantive Change	2024-12-05
DR 4300-003.pdf Supplementary Document	2024-09-20
Program Complaint Form-FY24-Revision AD 3027 estimates.xlsx Supplementary Document	2024-08-27
Supporting Statement 2024 Program Complaint Form 0508-0002-9-18-24 Clean-Copy.docx Supporting Statement A	2024-09-20

IC Document Collections

IC ID	Document Title	Status
987	Program Discrimination Complaint Form (Individuals) Form and Instruction	Modified
198399	Program Discrimination Complaint Form (State, Local and Tribal Government) Form	Unchanged
198398	Program Discrimination Complaint Form (Private Sector) Form	Unchanged

ICR Details

OMB Control No: 0508-0002	ICR Reference No: 202411-0508-001
Status: Received in OIRA	Previous ICR Reference No: 202408-0508-001
Agency/Subagency: USDA/AgOCR	Agency Tracking No:
Title: USDA Program Discrimination Complaint Form
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  Yes
Type of Review Request: Regular	Date Submitted to OIRA: 12/05/2024

	Requested	Previously Approved
Expiration Date	09/30/2027	09/30/2027
Responses	280	280
Time Burden (Hours)	280	280
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

IC Title	Form No.	Form Name
Program Discrimination Complaint Form (Individuals)	AD 3027 HEB, AD 3027TAG, AD 3027 PUN, AD 3027 GER, AD 3027 CHIT, AD 3027 HTC, AD 3027 ITA, AD 3027 JAPANESE, AD 3027 POL, AD 3027 POL, AD 3027 RUS, AD 3027 ENG, AD 3027 FRA, AD 3027 SPA, AD 3027 ARA, AD 3027 KOR, AD 3027 Simplified Chinese, AD 3027 URD, AD 3027 VIE, AD 3027 YID	USDA Program Discrimination Complaint Form ,   USDA Program Discrimination Complaint Form ,   USDA Program Complaint Discrimination Form ,   USDA Program Complaint Discrimination Form ,   USDA Program Complaint Discrimination Form ,   USDA Program Complaint Discrimination Form ,   USDA Program Discrimination Complaint Form ,   USDA Program Discrimination Complaint Form ,   USDA Program Complaint Discrimination Form ,   USDA Program Discrimination Complaint Form ,   USDA Program Complaint Discrimination Form ,   USDA Program Discrimination Complaint Form ,   USDA Program Discrimination Complaint Form ,   USDA Program Discrimination Complaint Form ,   USDA Program Discrimination Complaint Form ,   USDA Program Discrimination Complaint Form ,   USDA Program Discrimination Complaint Form ,   USDA Program Discrimination Complaint Form ,   USDA Program Discrimination Complaint Form ,   USDA Program Discrimination Complaint Form
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-v7-July-31-2024-Draft_EN_Fillable_Remediat, AD-3027 ES Fillable Remediated, 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

	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	280	0	0	0	0
Annual Time Burden (Hours)	280	280	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:

---

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 Office of the Assistant Secretary for Civil Rights (OASCR) received approval for the renewal of Agriculture Department Form # 3027. Although, OMB approved the renewal of the English version of the form with documented changes to enhance and improve the use of the form, the Spanish version of the form was inadvertently omitted from the renewal process. The renewal of the English version of this data collection form was approved on September 30, 2024, under OMB Control No. 0508-0002. Although the renewal of the English version of the form was renewed without the Spanish version, Paper-Work Reduction Act indicators (burden hours or costs to the government) are not impacted with an increase in the number languages for which the form is made available. During the renewal process OASCR embarked on the opportunity to improve the content and structure of the form based on Stakeholder input. The rationale for producing the document at a minimum of 10 languages is based on the following information. USDA provides funds an array of services that can be made accessible to otherwise eligible persons who are not proficient in the English language. USDA is committed to improving the accessibility of these services to eligible Limited English Proficiency (LEP) persons, as a goal that reinforces its equally important commitment to promoting program services. To this end, Executive Order # 13166 requires each Federal agency shall examine the services it provides and develop and implement a system by which LEP persons can meaningfully access those services consistent with, and without unduly burdening, the fundamental mission of the agency.

Approved RCFs using this ICR

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: 12/05/2024

---