SSA collects information on Form SSA-437-BK to investigate and formally resolve complaints of discrimination based on disability, race, color, national origin (including limited English language proficiency), sex, sexual orientation, age, religion, or retaliation for having participated in a proceeding under this administrative complaint process in connection with an SSA program or activity. Individuals who believe SSA discriminated against them on any of the above bases may file a written complaint of discrimination. SSA uses the information to: (1) identify the complaint; (2) identify the alleged discriminatory act; (3) establish the date of such alleged action; (4) establish the identity of any individual(s) with information about the alleged discrimination; and (5) establish other relevant information that would assist in the investigation and resolution of the complaint.
This form has no bearing on any right to pursue, obtain, or keep Social Security benefits. The civil rights complaint process and the use of this form is entirely voluntary. SSA will also accept a letter or other written communication in the alternative to this form. Individuals do not need to use this form or submit a letter or otherwise exhaust administrative remedies before filing a discrimination lawsuit in U.S. District Court. There is no survey associated with this form. Respondents can submit the form by mail or email. Respondents may fill out the form with help from a person they choose, such as a relative, friend, or lawyer. They will not need information from others to complete it. SSA uses its existing Microsoft Office software to collect and work with incoming complaints. The Respondents are individuals who believe SSA, or SSA employees, contractors, or agents, discriminated against them in connection with programs or activities conducted by SSA.
US Code:
5 USC 301
Name of Law: The Federal Housekeeping Statute
EO: EO 13160 Name/Subject of EO: Ensuring Equal Opportunity in Federally Conducted Education and Training Programs
US Code:
29 USC 794(a)
Name of Law: Rehabilitation Act
US Code:
42 USC 902(a)(5)
Name of Law: Social Security Act
EO: EO 13166 Name/Subject of EO: Improving Access to Services for Persons With Limited English Proficiency
When we last cleared this IC in 2023, the burden was 500 hours. However, we are currently reporting a burden of 600 hours. This change stems from an increase in the number of responses from 500 to 600. There is no change to the burden time per response. Although the number of responses changed, SSA did not take any actions to cause this change. These figures represent current Management Information data.
* Note: The total burden reflected in ROCIS is 750, while the burden cited in #12 of the Supporting Statement is 600. This discrepancy is because the ROCIS burden also reflects the learning costs. In contrast, the chart in #12 of the Supporting Statement reflects actual burden.
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:
(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;
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.
Form SSA-437-BK Discrimination Complaint Form
Addendum - 0585.docx
Discrimination Complaint Form