Information Collection

Federal Government

IC 232542 under ICR 202506-3060-007 · OMB 3060-1258.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Alternate Dispute FCC Form 5628 Federal Government	Form
Alternate Dispute FCC Form 5628 ADR-Intake-Form-Final-June 24 2025.docx	Form

IC Title:

Federal Government

Agency IC Tracking Number:

EEO Director

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	Alternate Dispute Resolution Intake Form				Yes	Yes	Fillable Fileable Signable

Line of Business: General Government

Subfunction: Central Fiscal Operations

Privacy Act System of Records

Title: FCC/OWD-2

FR Citation: 84 FR 14374

Number of Respondents: 2

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	2	2
Annual IC Time Burden (Hours)	6	6
Annual IC Cost Burden (Dollars)	1,875	1,875

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.

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