Information Collection

Complaint Forms for Discrimination; Health Information Privacy Complaints

IC 10401 under ICR 201209-0990-003 · OMB 0990-0269.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0990-0269_CRD Complaint Form (with supporting docs).pdf	Other-forms
0990-0269_Attachment%20A[1].pdf 0990-0269_Attachment%20A[1]	IC Document

IC Title:

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-forms			0990-0269_CRD Complaint Form (with supporting docs).pdf		No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,493

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	3,493	456	3,037
Annual IC Time Burden (Hours)	2,620	342	2,278
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
0990-0269_Attachment%20A[1]	0990-0269_Attachment%20A[1].pdf	09/28/2012

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