Information Collection

Complaint Forms for Discrimination; Health Information Privacy Complaints

IC 10401 under ICR 201512-0945-001 · OMB 0945-0002.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0945-0002 can be found here:

Documents and Forms

Document Name Document Type
0945-0002 CivilRightscomplaintform HH 12-3-15.pdf Other-form

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-form			0945-0002 CivilRightscomplaintform HH 12-3-15.pdf		Yes	Yes	Fillable Fileable

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: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3,493	3,493
Annual IC Time Burden (Hours)	2,620	2,620
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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