Individual Complaint of Employment Discrimination

Forms and Documents

Document Name	Status
Form DOT Form 1050-1 Individual Complaint of Employment Discrimination Form	Modified
2105-0556_EEO_Forms_30_Day_Notice_2012-29483.pdf Supplementary Document	2013-03-13
GINA.pdf Supplementary Document	2012-10-24
Supporting Statement.MH.10-17-12.doc Supporting Statement A	2012-10-17
FR 60-day Notice 5-18-12.pdf Supplementary Document	2012-10-17
29 CFR Part 1614.pdf Supplementary Document	2009-07-31

IC Document Collections

IC ID	Document Title	Status
44070	Individual Complaint of Employment Discrimination Form	Modified

ICR Details

OMB Control No: 2105-0556	ICR Reference No: 201210-2105-001
Status: Historical Active	Previous ICR Reference No: 200907-2105-002
Agency/Subagency: DOT/OST	Agency Tracking No:
Title: Individual Complaint of Employment Discrimination
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/19/2013
	Date Received in OIRA: 03/13/2013
Terms of Clearance: OMB notes this collection expired without DOT discontinuing it, which is a violation of PRA procedures. If DOT decides to request extension of this collection, it must enter the burden estimates for each IC in ROCIS (rather than uploading them all under one burden estimate) and include an estimate of the cost of this collection to the Federal gov't. This collection is approved for one year.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2014	36 Months From Approved
Responses	10	0	0
Time Burden (Hours)	30	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: DOT needs requested information to process complaints of discrimination filed by applicants for employment with the agency.

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Authorizing Statute(s): PL: Pub.L. 110 - 233 122 STAT. 881 Name of Law: Genetic Information Nondiscrimination Act of 2008.
   US Code: 42 USC 2000ff Name of Law: PROHIBITING EMPLOYMENT DISCRIMINATION ON THE BASIS OF GENETIC INFORMATION
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 29747	05/18/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 72905	12/06/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Individual Complaint of Employment Discrimination	DOT Form 1050-1 , DOT Form 1050-9, DOT Form 1050-2, DOT Form 1050-3 , DOT Form 1050-4, DOT Form 1050-6, DOT Form 1050-5, DOT Form 1050-7 , DOT Form 1050-8, DOT Form 1050-10, DOT Form 1050-11, DOT Form 1050-12	EEO COUNSELOR CHECKLIST ,   Mediation Intake.doc ,   Agreement to Mediate ,   Exit Survey for Mediation Participants ,   NOTICE OF RIGHT TO FILE A DISCRIMINATION COMPLAINT ,   Extension of EEO Counseling ,   Notice of Rights and Responsibilities ,   Individual Complaint of Employment ,   DESIGNATION OF REPRESENTATIVE FORM ,   Final Agency Decision Request Form ,   WAIVER OF RIGHT TO ANONYMITY ,   Request for Mediation

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ICR Summary of Burden

	Total Approved	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	10	0	0	0	0	10
Annual Time Burden (Hours)	30	0	0	0	20	10
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: DOT has changed the hours necessary for completing the forms since the OMB's approval of the form in 2009. This includes the addition of DOT Form 1050-11 ("Waiver of Right to Anonymity") and DOT Form 1050-12 ("Request for Mediation"). However, prior to 2009 the number of hours necessary for completing the form was changed from 2.5 hours to 1 hour. The reduction of 1.5 hours was based on the erroneous focus on only DOT F 1050-8, without factoring in the time required for the remaining forms.

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

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? Uncollected

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Common Form ICR:  No

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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: 03/13/2013

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