Complaint Forms for Discrimination; Health Information Privacy Complaints

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
OCR- COMPLAINT FORM CHANGE REQUEST MEMO.pdf	Justification for No Material/Nonsubstantive Change	Uploaded 2017-12-08	Available
0945-0002 CRD Complaint & Consent Forms MMN - 10-25-17.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2017-11-06	Available
0990-0269_Attachment%20A[1].pdf	Supplementary Document	Uploaded 2012-09-28	Available
0945-0002 Supporting Statement 11242015 Complaint forms.docx	Supporting Statement A	Uploaded 2015-12-29	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
190142	Health Information Privacy Complaint Form	Other-Form	Unchanged
10401	Complaint Forms for Discrimination; Health Information Privacy Complaints	Other-form	Modified

ICR Details

OMB Control No: 0945-0002	ICR Reference No: 201710-0945-003
Status: Historical Active	Previous ICR Reference No: 201512-0945-001
Agency/Subagency: HHS/OCR	Agency Tracking No:
Title: Complaint Forms for Discrimination; Health Information Privacy Complaints
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/11/2017
	Date Received in OIRA: 11/07/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2019	04/30/2019	04/30/2019
Responses	13,779	0	13,779
Time Burden (Hours)	10,335	0	10,335
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: 29 USC 794 Name of Law: Section 504 of the Rehabilitation Act of 1973
   US Code: 42 USC 2000d Name of Law: Title VI of the Civil Rights Act of 1964
  

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:
	80 FR 63561	10/20/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 80778	12/28/2015
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

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

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ICR Summary of Burden

table that charts list 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	13,779	0	0	0	0
Annual Time Burden (Hours)	10,335	10,335	0	0	0	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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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: 11/07/2017

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