Information Collection

Complaint Forms for Discrimination; Health Information Privacy Complaints

IC 10401 under ICR 200803-0990-003 · OMB 0990-0269.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0269 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0990-0269CRD Complaint Form - HHS 699 FINAL.doc	Other-complaint form
0990-0269HIP Complaint Form - HHS 700 FINAL.doc	Other-complaint

IC Title:

Complaint Forms for Discrimination; Health Information Privacy Complaints

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-complaint form			0990-0269CRD Complaint Form - HHS 699 FINAL.doc		No	No	Paper Only
Other-complaint			0990-0269HIP Complaint Form - HHS 700 FINAL.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	12,400	12,400
Annual IC Time Burden (Hours)	9,300	9,300
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.