Complaint Forms for Discrimination; Health Information Privacy Complaints

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

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: Modified

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
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 %

	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

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.