Complaint Forms for Discrimination; Health Information Privacy Complaints

Complaint Forms for Discrimination; Health Information Privacy Complaints

OMB: 0990-0269

IC ID: 10401

Information Collection (IC) Details

View Information Collection (IC)

Complaint Forms for Discrimination; Health Information Privacy Complaints
 
No Modified
 
Voluntary
 

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

Health Health Care Services

 

3,493 0
   
Individuals or Households
 
   20 %

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

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.

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