Discrimination Complaint Form

Complaint of Discrimination Under Section 504, Section 508 or Title VI

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1405-0220 can be found here:

Documents and Forms

Document Name Document Type
Form DS4282 Discrimination Complaint Form Form and Instruction
DS4282 Discrimination Complaint Form DS4282 12-7-2015.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Discrimination Complaint Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	DS4282	Discrimination Complaint Form	DS4282 12-7-2015.pdf		No		Fillable Fileable

Line of Business: Litigation and Judicial Activities

Subfunction: Legal Investigation

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	10	10
Annual IC Time Burden (Hours)	10	10
Annual IC Cost Burden (Dollars)	10	10

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.