Complaint Forms for Civil Rights and Conscience; Health Information Privacy Security and Breach Notification Complaints

Forms and Documents

Document	Type	Status	Availability
Form HHS-700 Civil Rights and Conscience Complaint	Form	Modified	Available
Form HHS-700 Health Information Privacy, Security and Breach Notification Complaint	Form	Modified	Available
OMB Submission_Supporting Statement for OMB 0945-0002_03012 final 30-day.docx	Supporting Statement A	Uploaded 2026-03-05	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
236663	Civil Rights and Conscience Complaint	Form	Modified	Civil Rights and Conscience Complaint
236663	Civil Rights and Conscience Complaint	Form	Modified
190142	Health Information Privacy, Security and Breach Notification Complaint	Form	Modified	Health Information Privacy, Security and Breach Notification Complaint
190142	Health Information Privacy, Security and Breach Notification Complaint	Form	Modified

ICR Details

OMB Control No: 0945-0002	ICR Reference No: 202512-0945-001
Status: Received in OIRA	Previous ICR Reference No: 202209-0945-001
Agency/Subagency: HHS/OCR	Agency Tracking No:
Title: Complaint Forms for Civil Rights and Conscience; Health Information Privacy Security and Breach Notification Complaints
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 03/05/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	05/31/2026
Responses	47,453	45,838
Time Burden (Hours)	35,607	34,379
Cost Burden (Dollars)	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:
	90 FR 61404	12/31/2025
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 10810	03/05/2026
Did the Agency receive public comments on this ICR? Yes

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

IC Title	Form No.	Form Name
Civil Rights and Conscience Complaint	HHS-700	Civil Rights and Conscience Complaint
Health Information Privacy, Security and Breach Notification Complaint	HHS-700	Health Information Privacy, Security and Breach Notification Complaint

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ICR Summary of Burden

	Total Request	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	47,453	45,838	0	0	1,615	0
Annual Time Burden (Hours)	35,607	34,379	0	0	1,228	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Based on examination of actual complaint levels over the past two years, OCR projects that OCR will average 15,468 civil rights related complaints per year and 31,985 privacy related complaints per year.

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Annual Cost to Federal Government:

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? No

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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: 03/05/2026

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