Complaint Forms for Discrimination; Health Information Privacy Complaints

Forms and Documents

Document Name	Status
0990-0269_Attachment%20A[1].pdf Supplementary Document	2012-09-28
0990-0269_Supporting Statement 20083112.docx Supporting Statement A	2012-11-07

IC Document Collections

IC ID	Document Title	Status
190142	Health Information Privacy Complaint Form Other-form	Modified
10401	Complaint Forms for Discrimination; Health Information Privacy Complaints Other-forms	Modified

ICR Details

OMB Control No: 0990-0269	ICR Reference No: 201209-0990-003
Status: Historical Active	Previous ICR Reference No: 200907-0990-003
Agency/Subagency: HHS/HHSDM	Agency Tracking No:
Title: Complaint Forms for Discrimination; Health Information Privacy Complaints
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/12/2012
	Date Received in OIRA: 09/28/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2015	36 Months From Approved	12/31/2012
Responses	13,779	0	11,981
Time Burden (Hours)	10,335	0	8,986
Cost Burden (Dollars)	0	0	0

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Abstract: 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.

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Authorizing Statute(s): 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
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 43826	07/26/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 59401	09/27/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

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

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ICR Summary of Burden

	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

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 09/28/2012

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