Workplace Discrimination Complaints

OMB 3060-1237

FCC employees, former employees and applicants for employment who believe they were denied equal employment opportunity based on race, color, religion, gender, national origin, age, physical or mental disability, genetic information and/or reprisal will complete FCC-5621 and FCC-5622.

The latest form for Workplace Discrimination Complaints expires 2023-05-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form FCC Form 5621 Federal Government Form
Form FCC Form 5622 Individuals or Households Form
Supporting Statement Forms 5621 and 5622 Workplace Discrimination_final version.docx Supporting Statement A
Federal Government Form
Individuals or Households Form

All Historical Document Collections

202305-3060-014 Approved without change	Extension without change of a currently approved collection	2023-05-30
202211-3060-023 Approved without change	No material or nonsubstantive change to a currently approved collection	2022-11-30
202206-3060-015 Approved without change	No material or nonsubstantive change to a currently approved collection	2022-06-21
202004-3060-043 Approved without change	Extension without change of a currently approved collection	2020-05-28
201704-3060-028 Approved without change	New collection (Request for a new OMB Control Number)	2017-05-10

OMB Details

Individuals or Households

Federal Enterprise Architecture: General Government - Central Fiscal Operations