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

Forms and Documents

Document Name	Status
Form DS4282 Discrimination Complaint Form Form and Instruction	Modified
Legal Authorities DS-4282 1405-0220.docx Supplementary Document	2019-05-09
Final DS-4282 Supporting Statement 6-12-2019.docx Supporting Statement A	2019-06-13

IC Document Collections

IC ID	Document Title	Status
217700	Discrimination Complaint Form Form and Instruction	Modified

ICR Details

OMB Control No: 1405-0220	ICR Reference No: 201905-1405-005
Status: Active	Previous ICR Reference No: 201603-1405-005
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Complaint of Discrimination Under Section 504, Section 508 or Title VI
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/21/2019
	Date Received in OIRA: 05/09/2019
Terms of Clearance: Clarified electronic submission capabilities.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2022	36 Months From Approved	06/30/2019
Responses	10	0	10
Time Burden (Hours)	10	0	10
Cost Burden (Dollars)	10	0	10

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Abstract: The DS-4282 will be used to submit complaints of discrimination under Title VI of the Civil Rights Act of 1964; and Sections 504 and 508 of the Rehabilitation Act of 1973.

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Authorizing Statute(s): US Code: 29 USC 794 Name of Law: Rehabilitation Act of 1973
   US Code: 42 USC 2000 Name of Law: Title VI of the Civil Rights Act of 1964
  

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:
	84 FR 3531	02/12/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 20181	05/08/2019
Did the Agency receive public comments on this ICR? Yes

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

IC Title	Form No.	Form Name
Discrimination Complaint Form	DS4282	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	10	10	0	0	0	0
Annual Time Burden (Hours)	10	10	0	0	0	0
Annual Cost Burden (Dollars)	10	10	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:

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Annual Cost to Federal Government: $4,000

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.     Yes

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.     Yes

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: 05/09/2019

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