Complaint Forms for Discrimination; Health Information Privacy Complaints

Forms and Documents

Document Name	Status
60-day FRN 0945-0002.pdf Supplementary Document	2019-06-21
OCR- COMPLAINT FORM CHANGE REQUEST MEMO.pdf Justification for No Material/Nonsubstantive Change	2017-12-08
0945-0002 CRD Complaint & Consent Forms MMN - 10-25-17.docx Justification for No Material/Nonsubstantive Change	2017-11-06
0990-0269_Attachment%20A[1].pdf Supplementary Document	2012-09-28
0945-0002 Supporting Statement 6-14-19.docx Supporting Statement A	2019-06-25

IC Document Collections

IC ID	Document Title	Status
236663	Civil Rights/Conscience Religious Freedom Discrimination Complaint Other-form	New
190142	Health Information Privacy Complaint Form Other-Form	Modified
10401	Complaint Forms for Discrimination; Health Information Privacy Complaints Other-form	Removed

ICR Details

OMB Control No: 0945-0002	ICR Reference No: 201906-0945-004
Status: Active	Previous ICR Reference No: 201710-0945-003
Agency/Subagency: HHS/OCR	Agency Tracking No:
Title: Complaint Forms for Discrimination; Health Information Privacy Complaints
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/12/2019
	Date Received in OIRA: 06/25/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2022	36 Months From Approved	11/30/2019
Responses	33,732	0	13,779
Time Burden (Hours)	25,299	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:
	84 FR 9802	03/18/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 29525	06/24/2019
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Complaint Forms for Discrimination; Health Information Privacy Complaints
Health Information Privacy Complaint Form
Civil Rights/Conscience Religious Freedom Discrimination Complaint

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ICR Summary 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	33,732	13,779	0	19,953	0	0
Annual Time Burden (Hours)	25,299	10,335	0	14,964	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Consequently, while the burden per complaint remains unchanged at 45 minutes, total burden has increased from to 10,335 hours to 25,299 hours. OCR has begun addressing new civil rights, conscience and religious freedom, and health privacy responsibilities, as well as enforcing initiatives in areas that are Secretary and Administration priorities. Increased outreach and expanded responsibilities likely have contributed to the increase in the number of complaints.

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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: 06/25/2019

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