Discrimination Complaint Form

Documents and Forms

Document Name Document Type
Form SSA-437-BK Discrimination Complaint Form Form and Instruction
Revised PA & PRA Statements.pdf Other-Revised PA & PRA Statements
Revised PA & PRA Statements.pdf Other-Revised PA & PRA Statements
SSA-437-BK Discrimination Complaint Form SSA-437-BK - Revised.pdf Form and Instruction
SSA-437-BK Discrimination Complaint Form SSA-437-BK - Revised.pdf Form and Instruction
SSA-437-BK - Current.pdf SSA-437-BK - Current IC Document
SSA-437-BK - Current.pdf SSA-437-BK - Current IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Discrimination Complaint Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-437-BK	Discrimination Complaint Form	SSA-437-BK - Revised.pdf		Yes	No	Fillable Fileable
Other-Revised PA & PRA Statements			Revised PA & PRA Statements.pdf		Yes	No	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	500	245	255
Annual IC Time Burden (Hours)	500	245	255
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-437-BK - Current	SSA-437-BK - Current.pdf	09/02/2022

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.