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Complaint Forms for Discrimination; Health Information Privacy Complaints
Complaint Forms for Discrimination; Health Information Privacy Complaints
OMB: 0990-0269
IC ID: 10401
OMB.report
HHS/HHSDM
OMB 0990-0269
ICR 200604-0990-002
IC 10401
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0269 can be found here:
2012-09-28 - Extension without change of a currently approved collection
2009-07-31 - Extension without change of a currently approved collection
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Complaint Forms for Discrimination; Health Information Privacy Complaints
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Migrated
Obligation to Respond:
Voluntary
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Federal Enterprise Architecture Business Reference Module
Line of Business:
Subfunction:
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
12,400
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
20 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
12,400
0
-11,400
0
0
23,800
Annual IC Time Burden (Hours)
9,300
0
-8,550
0
0
17,850
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.