Health Information Privacy Complaint Form

Complaint Forms for Discrimination; Health Information Privacy Complaints

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0945-0002 can be found here:

Documents and Forms

Document Name Document Type
0945-0002hipcomplaintform 12-3-15 HH.pdf Other-Form
0945-0002 -HIP complaint form package-508R.pdf Other-form

Information Collection (IC) Details

IC Title:	Health Information Privacy Complaint Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Form			0945-0002hipcomplaintform 12-3-15 HH.pdf		Yes	Yes	Fillable Fileable
Other-form			0945-0002 -HIP complaint form package-508R.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 25,299	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	25,299	15,013	10,286
Annual IC Time Burden (Hours)	18,974	11,259	7,715
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.