Information Collection

Complaint Forms for Discrimination; Health Information Privacy Complaints

IC 10401 under ICR 201710-0945-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
0945-0002 CivilRightscomplaintform HH 12-3-15.pdf	Other-form
CRD Complaint Consent Forms MMN - accepted changes 10-25-17.docx	Other-form

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:

table that charts list of 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
Other-form			CRD Complaint Consent Forms MMN - accepted changes 10-25-17.docx		Yes	Yes	Fillable Printable

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 %

table that charts list of burden
	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

table that charts IC Documents
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.