Information Collection

Civil Rights and Conscience Complaint

IC 236663 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⚠️ Notice: This information collection may be referencing outdated material.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 Civil Rights and Conscience Complaint	Form
0945-0002 Civil Rights and Conscience Complaint Form Final 7-7-22 CR-CRF HH.docx	Form
0945-0002 Civil Rights and Conscience Complaint Form Final 7-7-22 CR-CRF HH.docx	Form

IC Title:

Civil Rights and Conscience 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
Form	0945-0002	Civil Rights and Conscience Complaint Form	Final 7-7-22 CR-CRF HH.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15,446

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	15,446	7,013	8,433
Annual IC Time Burden (Hours)	11,585	5,260	6,325
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.