Complaint Forms for Discrimination; Health Information Privacy Complaints

ICR 201710-0945-003

OMB: 0945-0002

Federal Form Document

Forms and Documents
Document
Name
Status
Justification for No Material/Nonsubstantive Change
2017-12-08
Justification for No Material/Nonsubstantive Change
2017-11-06
Supplementary Document
2012-09-28
Supporting Statement A
2015-12-29
ICR Details
0945-0002 201710-0945-003
Historical Active 201512-0945-001
HHS/OCR
Complaint Forms for Discrimination; Health Information Privacy Complaints
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved with change 12/11/2017
Retrieve Notice of Action (NOA) 11/07/2017
  Inventory as of this Action Requested Previously Approved
04/30/2019 04/30/2019 04/30/2019
13,779 0 13,779
10,335 0 10,335
0 0 0

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.

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
  
None

Not associated with rulemaking

  80 FR 63561 10/20/2015
80 FR 80778 12/28/2015
No

2
IC Title Form No. Form Name
Complaint Forms for Discrimination; Health Information Privacy Complaints
Health Information Privacy Complaint Form

  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
No
No

$0
No
    Yes
    Yes
No
No
No
Uncollected
Sherrette Funn-Coleman 2026905683

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
11/07/2017


© 2024 OMB.report | Privacy Policy