DHS Civil Rights Compliance Form

OMB Control No: 1601-0024	ICR Reference No: 201801-1601-001
Status: Active	Previous ICR Reference No: 201611-1601-001
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: Approved with change	Conclusion Date: 01/30/2018
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/30/2018
Terms of Clearance: During the course of this review, the agency made a significant effort to reduce burden on respondents. The agency will continue to keep an eye toward any ways to further streamline or reduce burden as it implements this new collection.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2021	36 Months From Approved
Responses	2,220	0	0
Time Burden (Hours)	6,660	0	0
Cost Burden (Dollars)	0	0	0

---

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.

---

Authorizing Statute(s): 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    US Code: 20 USC 1681 Name of Law: Title IX of the Education Amendments of 1972

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

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

---

Number of Information Collection (IC) in this ICR: 1

IC Title Form No. Form Name DHS Civil Rights Compliance Form 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

---

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	2,220	0	0	4,385	-2,165	0
Annual Time Burden (Hours)	6,660	0	0	15,320	-8,660	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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.

---

Annual Cost to Federal Government: $466,489

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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

Agency Contact: Tyrone Huff 202 447-0106 [email protected]

---

Common Form ICR:  No

---

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: 01/30/2018

---