Information Collection

Complaint Forms for Discrimination; Health Information Privacy Complaints

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Complaint Forms for Discrimination; Health Information Privacy Complaints	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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-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 %

	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

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.