Health Information Privacy Complaint Form

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⚠️ Notice: This information collection may be referencing outdated material.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
0990-0269-HHS-700 6-29-2009.pdf Other-form

Information Collection (IC) Details

IC Title:	Health Information Privacy Complaint Form	Agency IC Tracking Number:

Is this a Common Form?		IC Status: New

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-form			0990-0269-HHS-700 6-29-2009.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 8,944	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	8,944	8,944
Annual IC Time Burden (Hours)	6,708	6,708
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.