Discrimination Complaint Form

Forms and Documents

Document Name	Status
Form SSA-437 Discrimination Complaint Form Form and Instruction	Modified
Addendum--0585.doc Supplementary Document	2007-03-26
Supporting Statement--0585.doc Supporting Statement A	0000-00-00
ssa-437.pdf Supplementary Document	2006-03-31

IC Document Collections

IC ID	Document Title	Status
9560	Discrimination Complaint Form Form and Instruction	Modified

ICR Details

OMB Control No: 0960-0585	ICR Reference No: 200701-0960-009
Status: Historical Active	Previous ICR Reference No: 200402-0960-003
Agency/Subagency: SSA	Agency Tracking No:
Title: Discrimination Complaint Form
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: 05/16/2007
	Date Received in OIRA: 03/26/2007
Terms of Clearance: This request is approved consistent with the revised supporting statement and instrument received in OIRA on 5/3/07, which note material changes to the instrument for clarification purposes. SSA will send the instrument to FMT to be standardized in format upon OMB approval prior to circulation.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2010	36 Months From Approved	05/31/2007
Responses	140	0	98
Time Burden (Hours)	140	0	98
Cost Burden (Dollars)	0	0	0

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Abstract: The information collected on form SSA–437 is used by SSA to investigate and formally resolve complaints of discrimination based on race, color, sex, age, religion, disability, retaliation, and national origin, including limited or no ability with English in any program or activity conducted by SSA. A person who believes that he or she has been discriminated against on any of the above bases may file a written complaint of discrimination. The information will be used to identify the complainant; identify the alleged discriminatory act; ascertain the date of such alleged act; obtain the identity of any individual(s) with information about the alleged discrimination; and ascertain other relevant information that would assist in the investigation and resolution of the complaint. The respondents are individuals who believe they have been discriminated against by SSA or by SSA’s employees, contractors or agents in programs or activities conducted by SSA.

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Authorizing Statute(s): US Code: 5 USC 301 Name of Law: null
   US Code: 29 USC 794(a) Name of Law: null
   US Code: 42 USC 902(a)(5) Name of Law: null
   EO: EO 13166 Name/Subject of EO: Improving Access to Services for Persons With Limited English Proficiency
  

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:
	72 FR 2081	01/17/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 13851	03/23/2007
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
Discrimination Complaint Form	SSA-437	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	140	98	0	0	42	0
Annual Time Burden (Hours)	140	98	0	0	42	0
Annual Cost Burden (Dollars)	0	0	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: The increase in the burden hours from 98 to 140 is based on the increase in the number of complaints we have received per year over the past three years.

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Annual Cost to Federal Government: $7,500

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

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

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: 03/26/2007

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