Information Collection

Medical Complaint Form

IC 229902 under ICR 201801-0970-014 · OMB 0970-0509.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0509 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Medical Complaint Form	Form and Instruction
1 Medical Complaint Form Medical Complaint_FINAL.docx	Form and Instruction

IC Title:

Medical Complaint Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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
Form and Instruction	1	Medical Complaint Form	Medical Complaint_FINAL.docx		Yes	Yes	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 120

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100,320	100,320
Annual IC Time Burden (Hours)	21,067	21,067
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.