Form AMJP 1A.2.2 AMJP 1A.2.2 Reciepient Report of Employment Action

Form AMJP-1A.2.2

OMB CONTROL NUMBER: 2106-0048
EXPIRATION DATE: 11/30/2021

FORM AMJP-1A.2.2
AMJP RECIPIENT REPORT TO USDOT OF EMPLOYMENT ACTION
AFFECTING THE ELIGIBLE EMPLOYEE GROUP

PAPERWORK REDUCTION ACT PUBLIC BURDEN STATEMENT
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor
shall a person be subject to a penalty for failure to comply with a collection of information
subject to the requirements of the Paperwork Reduction Act unless that collection of information
displays a currently valid OMB Control Number. The OMB Control Number for this information
collection is 2106-0048. Public reporting for this collection of information is estimated to be
approximately 90 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, completing and reviewing the
collection of information. All responses to this collection of information are required to obtain or
retain a benefit (pursuant to the American Rescue Plan Act of 2021 (ARPA), Public Law (P.L.)
117-2, § 7201-7202). Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden to: Information
Collection Clearance Officer, Department of Transportation, OST-S-83, 1200 New Jersey
Avenue S.E., Washington, DC 20590.

OMB CONTROL NUMBER: 2106-0048
EXPIRATION DATE: 11/30/2021

Form AMJP-1A.2.2

FORM AMJP-1A.2.2
AMJP RECIPIENT REPORT TO USDOT OF EMPLOYMENT ACTION
AFFECTING THE ELIGIBLE EMPLOYEE GROUP
AMJP Recipient Business Name
AMJP Agreement Number

69A345

AMJ0

Date of Employment Action
Nature of Employment Action

(Select One)

Anticipated Reduction in Compensation
for Period of Performance
Narrative Explanation of Employment Action:

Provide a brief description of the employment action with reference to relevant portions of the employer policy
under which the action was taken. Include the individual’s Eligible Employee Group (EEG) member ID
consistent with the current AMJP Recipient Notification to USDOT of EEG Composition (Form AMJP-1A.6.5).
Do not include any personally identifiable information about employees; redact that information as necessary.

Example: Employee ID #1009 has been removed from the EEG because they were suspended for
reasons related to performance and conduct, consistent with corporate policy.

Attachments:

Provide a list identifying all attachments. Attach relevant sections of the employer policy or policies under which the
reported action was taken. Attach documentation of the anticipated reduction in compensation, including
documentation of the affected wages, salaries, and benefits included in the total base compensation for the affected
employee. Attach other documentation as needed to support the narrative description or justification above. Do not
include any personally identifiable information about employees.

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OMB CONTROL NUMBER: 2106-0048
EXPIRATION DATE: 11/30/2021

Form AMJP-1A.2.2

Certification:
I certify under penalty of perjury that the information above and attached is true and correct, and
I have authority to submit this information to the USDOT on behalf of the Recipient.
I acknowledge that false, fictitious, or fraudulent information, or the omission of any material
fact, may subject me to criminal penalties, civil penalties, or both. (See 18 U.S.C. 287; 18 U.S.C.
1001; 31 U.S.C. 3729; 31 U.S.C. 3802).
Signature

Date

Name of Signing Official

Title of Signing Official

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