Information Collection

DHS Civil Rights Compliance Form 3095

IC 224608 under ICR 202103-1601-002 · OMB 1601-0024.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1601-0024 can be found here:

Documents and Forms

Document Name Document Type
Form DHS Form 3095 DHS Civil Rights Compliance Form 3095 Form and Instruction
DHS Form 3095 DHS Civil Rights Compliance Form DHS Form 3095.pdf dhs.gov/resources-recipients-dhs-financial-assistance Form and Instruction
DHS Form 3095 DHS Civil Rights Compliance Form DHS Form 3095.pdf dhs.gov/resources-recipients-dhs-financial-assistance Form and Instruction
DHS Civil Rights Evaluation Tool Proposed updates 3 2021.pdf DHS Form 3095 Proposed Updates IC Document
DHS Civil Rights Evaluation Tool Proposed updates 3 2021.pdf DHS Form 3095 Proposed Updates IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	DHS Civil Rights Compliance Form 3095	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 44 CFR Part 7 6 CFR Part 21 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	DHS Form 3095	DHS Civil Rights Compliance Form	DHS Form 3095.pdf	http://dhs.gov/resources-recipients-dhs-financial-assistance	Yes	Yes	Fillable Fileable

Line of Business: Homeland Security

Subfunction: Key Asset and Critical Infrastructure Protection

Privacy Act System of Records
Title: DHS/ALL-029	FR Citation: 75 FR 39266

Number of Respondents: 2,929	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,962	-258	2,220
Annual IC Time Burden (Hours)	5,886	-774	6,660
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
DHS Form 3095 Proposed Updates	DHS Civil Rights Evaluation Tool Proposed updates 3 2021.pdf	03/16/2021

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