Privacy Act Statement: The information in this form is collected pursuant to the authority found in 5 U.S.C. 301 and 44 U.S.C. 3101. Providing information about your complaint, injury, or illness on this form is voluntary. If you do not provide all or some of the information, the Department of Justice may not be able to effectively address issues raised in your submission. The purpose for collecting information about your complaint, injury or illness is to identify and address potentially unsafe working conditions, assess, investigate and evaluate the overall safety of your work site, and provide necessary information for possible policy and procedural changes. The information we collect may be disclosed as permitted by the Privacy Act of 1974, 5 U.S.C. 552a, and all applicable Routine Uses, which include, but are not limited to: investigating or prosecuting violations or potential violations related to complaints and reports of injuries that occur in the workplace, and referring complaints or information about your injury or illness to other federal, tribal, state or local agencies. The complete list of routine uses related to this collection may be found in Justice/USA-003 “Citizen Complaint Files,” 54 Fed. Reg. 42,090 (October 13, 1989), 66 Fed. Reg. 8,425 (January 31, 2001), and 82 Fed. Reg. 24,147 (May 25, 2017). We understand that some of the information you provide may include personally identifiable information and health related data. The Department is committed to protecting the confidentiality of all the information you provide to us. The Department of Justice’s full Privacy Statement can be found at: https://www.justice.gov/doj/privacy-policy.
The collection, use and dissemination of information on this form is in accordance with the Paperwork Reduction Act of 1995, 44 U.S.C. 3507. This information is for the purpose of allowing the United States Attorney’s Office for the Southern District of New York to engage in the authorized collection of information about potentially unsafe working environments. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless that collection displays a currently valid Office of Management and Budget (OMB) control number. The estimated average burden associated with this collection is 20 minutes per response, depending on individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to: USANYS.PRA220714@usdoj.gov.
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