Program Discrimination Complaint Form Change Reequest

OMB Control Number: 0508-0002

Title of Clearance: USDA Program Discrimination Complaint Form

Changes: The specific changes to the Form 0508-0002 are as follows:

All changes are cosmetic, no major changes.

1. Instructions located on Page 1 of the approved form (consisting of Purpose, Filing Deadline, Where to File Complaint, etc.) is moved to Page 2 labeled “Instructions”, on the proposed form.

2. Questions and requested information were reformatted, organized, and labeled on the proposed form as follow: “Complainant Information,” “Representative Information,” “Complaint Information,” “Remedies,” and “Instructions.”

3. Under Purpose, 1st paragraph, 2nd sentence on approved form: Changed the order of the bases for consistency with departmental regulations and added gender identity and expression as bases under sex in “( )”, on the proposed form.

Order of bases changed from: race, color, national origin, religion, sex, disability, age, marital status, sexual orientation, family/parental status, income derived from public assistance program and political beliefs.

To: race, color, national origin, religion, sex (including gender identity and expression), sexual orientation, disability, age, marital status, family/parental status, income derived from public assistance, program and political beliefs.

4. Under Purpose, 2^nd Paragraph on approved form, beginning sentence “You may also send a complaint by FAX or United States Postal Service Mail” moved to Page 2 under “WHERE TO FILE YOUR COMPLAINT” section on proposed form.

5. Line 9 on approved form “Best Way to Reach You”. Language “select one” deleted. Under Complainant Information, on proposed form.

6. “Representative Information Title” Added under Representative Information on proposed form.

7. Line 11 Language ““Do you have a representative (lawyer or other advocate) for this complaint?” on approved form changed to “Do you have a representative?” on proposed form.

8. Line 13, Language on approved form “if Yes is selected, please provide the following information about you representative” changed under Representative Information to “Do you have written authorization from representative? If so, please attach.”, on proposed form.

9. Line 15 on approved form “Number and Street, PO Box, Road or Route” changed to “Mailing Address.”, on proposed form.

10. Line 16 on approved form “City, State and Zip Code” language deleted and listed as mailing address on proposed form.

11. Line 17 on approved form “Telephone” changed to “Phone”, on proposed form.

12. Line 18, Question 1 on old form: “Who do you believe discriminated against you?

Use additional pages, if necessary. Name(s) of person(s) involved in the alleged discrimination (if known)”, on approved form moved under Complainant Information Question #5, “Who do you believe discriminated against you?” and added “the name(s) of person(s) involved in the alleged discrimination (if known)”, on proposed form.

1. Line 20 “Please” language on approved form changed to “Provide” on proposed form. and moved under Complainant Information as Question #1 and Question #2, on proposed form.

13. Question #1, Page 3 on approved form added title “Complaint Information (attach additional pages and supporting documentation as needed)” on proposed form.

14. Question #2, on page 4 of approved form, “What happened to you?” added “please include dates of each allegation” on proposed form, Question #6.

    1. Question #2, on approved form language, “State the date when the alleged discrimination occurred and then describe what happened. If the alleged discrimination occurred more than once, please provide the other dates and describe what happened” and “and please include any supporting documents that would help show what happened” deleted.

15. Added, Question #3, “Date of recent alleged discrimination (mm/dd/yyyy)” on proposed form.

16. Language, Question #3, on page 4 on approved form “Where did the discrimination occur, etc.”, moved to Complainant Information, #4 and added “Location and/or address of the office where discrimination occurred on proposed form”.

17. Language, Question #4, on page 4 on approve form is moved under Complainant Information, Question #7 on proposed form.

18. Language, Question #5, on page 5 on approve form is moved under Remedies, Question #8 on proposed form.

19. Language, Question #6, on page 5 on approved form is moved under Remedies, Question #9 and #10 on proposed form.

20. Contact language on Page 5 of approved form under “Mail Completed From to”, “Email Completed Form to”, “Telephone Numbers” moved to Page 2 under Instructions, “Where to file your complaint” on proposed form, as follow:

WHERE TO FILE YOUR COMPLAINT: You may submit your completed form or letter to USDA by:

Mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence, Ave, SW, STOP 9410, Washington, DC 20250-9410;

eFax: 1 (833) 256-1665 or (202) 690-7442; or

eMail: program.intake@usda.gov.

ADDED: You may also visit our website at: https://www.usda.gov/oascr/how-to-file-a-program-discrimination-complaint.