Alternative Dispute Resolution Form Requests, FCC Form 5628

Forms and Documents

Document Name	Status
Form Alternate Dispute Federal Government Form	Modified
Nonsubstantive change request for 3060-1258 (June 2025).docx Justification for No Material/Nonsubstantive Change	2025-06-24
ADR SS_final version June 2025.docx Supporting Statement A	2025-06-24

IC Document Collections

IC ID	Document Title	Status
268655	Individuals or Households	Unchanged
232542	Federal Government Form	Modified

ICR Details

OMB Control No: 3060-1258	ICR Reference No: 202506-3060-007
Status: Active	Previous ICR Reference No: 202405-3060-009
Agency/Subagency: FCC	Agency Tracking No: OWD
Title: Alternative Dispute Resolution Form Requests, FCC Form 5628
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Delegated
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/24/2025
	Date Received in OIRA: 06/24/2025
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2027	06/30/2027	06/30/2027
Responses	3	0	3
Time Burden (Hours)	13	0	13
Cost Burden (Dollars)	3,750	0	3,750

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Abstract: This information will be utilized by the Equal Employment Director to pursue the resolution of general workplace disputes, encompassing both informal and formal EEO complaints, and to facilitate the Commission's Alternative Dispute Resolution process. The Commission is submitting this collection to the Office of Management and Budget for review and approval.

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Authorizing Statute(s): US Code: 5 USC 571 Name of Law: Administrative Dispute Resolution Act
   EO: EO 12988 Name/Subject of EO: Civil Justice Reform
  

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:
	89 FR 25263	04/10/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 25263	04/10/2024
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Federal Government	Alternate Dispute Resolution Intake Form	FCC Form 5628
Individuals or Households

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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	3	3	0	0	0	0
Annual Time Burden (Hours)	13	13	0	0	0	0
Annual Cost Burden (Dollars)	3,750	3,750	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:

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Annual Cost to Federal Government: $13,990

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: 06/24/2025

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