Americans with Disabilities Act Discrimination Complaint Form

Forms and Documents

Document Name	Status
Form 1190-0009 Americans with Disabilities Act Discrimination Complaint Form Form	Modified
30 day OMB 1190-0009 83 FR 28866 06 21 2018.pdf Supplementary Document	2018-06-21
DRS title II supporting statement 1190-0009.docx Supporting Statement A	2018-06-21
Certification Stmt 2015.doc Supplementary Document	2015-02-19
Privacy Release_A.doc Supplementary Document	2012-04-23
CFR Complaint.docx Supplementary Document	2010-05-26
ADA Law 12131.docx Supplementary Document	2010-05-26

IC Document Collections

IC ID	Document Title	Status
12906	Americans with Disabilities Act Discrimination Complaint Form Form	Modified

ICR Details

OMB Control No: 1190-0009	ICR Reference No: 201806-1190-001
Status: Active	Previous ICR Reference No: 201502-1190-001
Agency/Subagency: DOJ/CRT	Agency Tracking No:
Title: Americans with Disabilities Act Discrimination Complaint Form
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/04/2018
	Date Received in OIRA: 06/21/2018
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2021	36 Months From Approved	08/31/2018
Responses	11,192	0	9,100
Time Burden (Hours)	8,394	0	4,550
Cost Burden (Dollars)	0	0	0

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Abstract: Under title II of the Americans with Disabilities Act, an individual who believes that he or she has been subjected to discrimination on the basis of disability by a public entity may, by himself or herself or by an authorized representative, file a complaint. This information collection form has been developed to simplify this process for complainants.

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Authorizing Statute(s): US Code: 42 USC 12131 Name of Law: Americans with Disabilities Act
  

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:
	83 FR 16903	04/17/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 28866	06/21/2018
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
Americans with Disabilities Act Discrimination Complaint Form	1190-0009	Americans with Disabilities Act Discrimination Complaint Form

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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	11,192	9,100	0	2,092	0	0
Annual Time Burden (Hours)	8,394	4,550	0	3,844	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a change in burden due to a more robust consideration of the manner in which the public submits complaints, to include both forms submitted on-line as well as forms submitted by mail.

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Annual Cost to Federal Government: $405,150

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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: 06/21/2018

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