Complaint Forms for Discrimination; Health Information Privacy Complaints

Complaint Forms for Discrimination; Health Information Privacy Complaints

OMB: 0945-0002

IC ID: 10401

Information Collection (IC) Details

View Information Collection (IC)

Complaint Forms for Discrimination; Health Information Privacy Complaints
 
No Removed
 
Voluntary
 

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

Health Health Care Services

 

3,493 0
   
Individuals or Households
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 0 0 -3,493 0 0 3,493
Annual IC Time Burden (Hours) 0 0 -2,620 0 0 2,620
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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