DHS Civil Rights Compliance Form

Forms and Documents

Document Name	Status
Form DHS Form 3095 DHS Civil Rights Compliance Form - Direct Service Providers and Educational Institutions Form and Instruction	New
Form DHS Form 3095 DHS Civil Rights Compliance Form - State or Tribal Form and Instruction	New
Published 30 Day FRN (1601-NEW_DHS Civil Rights Compliance Form).pdf Supplementary Document	2016-12-14
Published 60 Day FRN (1601-NEW_DHS Civil Rights Compliance Form).pdf Supplementary Document	2016-11-28
42 USC 6101.pdf Supplementary Document	2016-11-28
42 USC 2000d-1.pdf Supplementary Document	2016-11-28
29 USC 794.pdf Supplementary Document	2016-11-28
28 CFR Part 42.docx Supplementary Document	2016-11-28
20 USC 1681.pdf Supplementary Document	2016-11-28
1601-NEW_Supporting Statement A 12-16-2016.docx Supporting Statement A	2016-12-19
44 CFR Part 19.pdf Supplementary Document	2016-11-28
44 CFR Part 7.pdf Supplementary Document	2016-11-28
6 CFR Part 21.pdf Supplementary Document	2016-11-28
6 CFR Part 17.pdf Supplementary Document	2016-11-28

IC Document Collections

IC ID	Document Title	Status
224714	DHS Civil Rights Compliance Form - Direct Service Providers and Educational Institutions Form and Instruction	New
224608	DHS Civil Rights Compliance Form - State or Tribal Form and Instruction	New

ICR Details

OMB Control No: 1601-0024	ICR Reference No: 201611-1601-001
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: DHS/OS	Agency Tracking No:
Title: DHS Civil Rights Compliance Form
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn	Conclusion Date: 05/01/2017
	Date Received in OIRA: 12/19/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The purpose of the information collection is to advise recipients of their civil rights obligations; obtain an assurance of compliance from each recipient, and collect pertinent civil rights information to ascertain if the recipient has in place adequate policies and procedures to achieve compliance, and to determine what, if any, further action may be needed to ensure the recipient is in compliance and will carry out its programs and activities in a nondiscriminatory manner.

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Authorizing Statute(s): US Code: 20 USC 1681 Name of Law: Title IX of the Education Amendments of 1972
   US Code: 29 USC 794 Name of Law: Section 504 of the Rehabilitation Act of 1973
   US Code: 42 USC 2000d-1 Name of Law: Civil Rights Act of 1964
   US Code: 42 USC 6101 Name of Law: Age Discrimination Act of 1975
  

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:
	81 FR 65390	09/22/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 90372	12/14/2016
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
DHS Civil Rights Compliance Form - State or Tribal	DHS Form 3095	DHS Civil Rights Compliance Form
DHS Civil Rights Compliance Form - Direct Service Providers and Educational Institutions	DHS Form 3095	DHS Civil Rights Compliance Form

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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 new collection.

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Annual Cost to Federal Government: $466,489

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]? 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: 12/19/2016

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