Form Alternate Dispute Alternate Dispute FCC Form 5628

OMB Control No. 3060-1258 Estimated Time Per Response: 3 hrs.

FCC Form 5628

F ederal Communications Commission

EEO PROGRAM

ADR Intake Form

Case. No.: _____________________

Name	Position	Bureau	Phone

10. HAVE YOU FILED ANY OF THE FOLLOWING (CHECK ALL THAT APPLY)

Negotiated Grievance Administrative Grievance Unfair Labor Practice Charge EEO Complaint Harassment Complaint Under FCC Anti-Harassment Policy and Procedures, Prevention and Elimination of Harassment in the Workplace 11. BRIEFLY DESCRIBE THE DISPUTE

1

ADR Intake Form (cont’d)

12. PLEASE DESCRIBE EACH INDIVIDUAL’S INVOLVEMENT IN THE DISPUTE
13. EMPLOYEE SIGNATURE	14. DATE OF THIS REQUEST (Month, Day, Year)

FCC-5628, Effective Date: October 2018

PRIVACY ACT STATEMENT

Authority: The Federal Communications Commission (FCC) is authorized to pursue this collection pursuant to the authority contained in the Administrative Dispute Resolution Act, 5 U.S.C. § 571; and Civil Justice Reform, Executive Order 12998, 61 Fed. Reg. 4729 (Feb. 5, 1996).

Purpose: The principal purpose for collecting this information is to permit the FCC’s ADR Program to assist current and former employees, as well as applicants for employment, in exploring dispute resolution alternatives to resolve a variety of workplace disputes, including issues raised both within this form and issues that may arise among the parties from the information submitted herein. Additionally, the FCC collects and maintains this information to process, resolve, record and track requests for administrative dispute resolution services, by FCC managers, supervisors and employees. Information collected in connection with a request for alternative dispute resolution services is confidential and may be shared with FCC officials or FCC contractors when those other individuals need to know the information to make determinations resulting from an alternative dispute resolution request or to assist the ADR Manager in making such a determination.

Routine Uses: The records and information in the records may be used pursuant to the Routine Uses for the system found in the System of Records Notice FCC/OWD-2, Alternative Dispute Resolution (ADR) Program, posted at https://www.fcc.gov/managing-director/privacy-transparency/privacy-act-information#systems.

Effect of Disclosure: The provision of information is voluntary; however, if you do not provide this information, the FCC may not provide you with ADR Program services, and you may not receive important information.

PAPERWORK REDUCTION ACT STATEMENT

We have estimated that each response to this collection of information will take three hours. Our estimate includes the time to read the instructions, look through existing records, gather and maintain the required data, and actually complete and review the form or response. If you have any comments on this estimate, or on how we can improve the collection and reduce the burden it causes you, please write the Federal Communications Commission, AMD/PPM, Paperwork Reduction Project (3060-1258), Washington, DC 20554. We will also accept your comments via the Internet if you send them to pra@fcc.gov. Please DO NOT SEND COMPLETED REQUESTS TO THIS ADDRESS. Remember - you are not required to respond to a collection of information sponsored by the Federal government, and the government may not conduct or sponsor this collection, unless it displays a currently valid OMB control number or if we fail to provide you with this notice. This collection has been assigned an OMB control number of 3060-1258.

2