Discrimination Complaint Form

Forms and Documents

Document Name	Status
Form SSA-437-BK Discrimination Complaint Form Form and Instruction	Modified
Addendum - 0585 (Final).docx Supplementary Document	2022-09-20
Supporting Statement - 0585 (Final).docx Supporting Statement A	2022-09-20

IC Document Collections

IC ID	Document Title	Status
9560	Discrimination Complaint Form Form and Instruction	Modified

ICR Details

OMB Control No: 0960-0585	ICR Reference No: 202205-0960-002
Status: Received in OIRA	Previous ICR Reference No: 201904-0960-008
Agency/Subagency: SSA	Agency Tracking No:
Title: Discrimination Complaint Form
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 10/03/2022

	Requested	Previously Approved
Expiration Date	36 Months From Approved	10/31/2022
Responses	500	255
Time Burden (Hours)	500	255
Cost Burden (Dollars)	0	0

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Abstract: 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.

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Authorizing Statute(s): US Code: 5 USC 301 Name of Law: The Federal Housekeeping Statute
   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
   EO: EO 13160 Name/Subject of EO: Ensuring Equal Opportunity in Federally Conducted Education and Training Programs
  

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:
	87 FR 39153	06/30/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 57551	09/20/2022
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Discrimination Complaint Form	SSA-437-BK	Discrimination Complaint Form

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ICR Summary of Burden

	Total Request	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	500	255	0	0	245	0
Annual Time Burden (Hours)	500	255	0	0	245	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: When we last cleared this IC in 2019, the burden was 255 hours. However, we are currently reporting a burden of 500 hours. This change stems from an increase in the number of responses from 255 to 500. 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.

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Annual Cost to Federal Government: $7,500

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.     Yes

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.     Yes

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? No

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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: 10/03/2022

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