Complaint Forms for Discrimination; Health Information Privacy Complaints

ICR 201209-0990-003

OMB: 0990-0269

Federal Form Document

Forms and Documents
Document
Name
Status
Supplementary Document
2012-09-28
Supporting Statement A
2012-11-07
ICR Details
0990-0269 201209-0990-003
Historical Active 200907-0990-003
HHS/HHSDM
Complaint Forms for Discrimination; Health Information Privacy Complaints
Extension without change of a currently approved collection   No
Regular
Approved with change 12/12/2012
Retrieve Notice of Action (NOA) 09/28/2012
  Inventory as of this Action Requested Previously Approved
12/31/2015 36 Months From Approved 12/31/2012
13,779 0 11,981
10,335 0 8,986
0 0 0

Individuals may file written complaints with the Office for Civil Rights when they believe they have been discriminated against by programs or entities that receive Federal financial assistance from HHS or if they believe that, on or after April 14, 2003, their right to the privacy of protected health information has been violated. The complaint forms in this PRA submission provide the basic information needed by OCR to allow initial processing of such complaints.

US Code: 42 USC 2000d Name of Law: Title VI of the Civil Rights Act of 1964
   US Code: 29 USC 794 Name of Law: Section 504 of the Rehabilitation Act of 1973
  
None

Not associated with rulemaking

  77 FR 43826 07/26/2012
77 FR 59401 09/27/2012
No

2
IC Title Form No. Form Name
Health Information Privacy Complaint Form
Complaint Forms for Discrimination; Health Information Privacy Complaints

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 13,779 11,981 0 0 1,798 0
Annual Time Burden (Hours) 10,335 8,986 0 0 1,349 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
No
No
No
Uncollected
Sherrette Funn-Coleman 2026905683

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
09/28/2012


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