Civil Rights Discrimination Complaint

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0662 can be found here:

Documents and Forms

Document Name Document Type
Form 10-0381 Civil Rights Discrimination Complaint Form
10-0381 CIVIL RIGHTS DISCRIMINATION COMPLAINT 10-0381-fill.pdf www.va.gov/vaforms Form
10-0381 Discrimination Complaint VA Form 10-0381.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Civil Rights Discrimination Complaint	Agency IC Tracking Number:	2900-0662

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation: 38 CFR 18.501 45 CFR 90 38 CFR 15 38 CFR 18.401 38 CFR 18.1

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	10-0381	CIVIL RIGHTS DISCRIMINATION COMPLAINT	10-0381-fill.pdf	http://www.va.gov/vaforms	Yes	No	Fillable Printable
Form	10-0381	Discrimination Complaint	VA Form 10-0381.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Litigant, Tort Claimant, EEO Complainant and Third Party Recovery Files-VA	FR Citation: 47 FR 8

Number of Respondents: 183	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	183	183
Annual IC Time Burden (Hours)	46	46
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.