Information Collection

Health Information Privacy and Security Complaint

IC 190142 under ICR 202209-0945-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Form 0945-0002 Health Information Privacy and Security Complaint Health Information Privacy and Security Complaint	Form
0945-0002 -HIP complaint form package-508R.pdf	Other-form
0945-0002 -HIP complaint form package-508R.pdf	Other-form
0945-0002 Health Information Privacy and Security Complaint Final 7-7-22 HIP complaint HH_.docx	Form
0945-0002 Health Information Privacy and Security Complaint Final 7-7-22 HIP complaint HH_.docx	Form

IC Title:

Health Information Privacy and Security Complaint

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					Yes	Yes	Fillable Fileable
Form	0945-0002				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 30,392

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	30,392	5,093	25,299
Annual IC Time Burden (Hours)	22,794	3,820	18,974
Annual IC Cost Burden (Dollars)	0	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.

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