Information Collection

Health Information Privacy, Security and Breach Notification Complaint

IC 190142 under ICR 202512-0945-001 · OMB 0945-0002.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form HHS-700 Health Information Privacy, Security and Breach Notification Complaint Health Information Privacy, Security and Breach Notification Complaint	Form
HHS-700 Health Information Privacy, Security and Breach Notifica HIPAA Complaint Form clean edits 021826 (002).pdf ocrportal.hhs.gov/ocr/smartscreen/main.jsf	Form

IC Title:

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	HHS-700			https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 31,985

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	31,985	1,593	30,392
Annual IC Time Burden (Hours)	23,989	1,195	22,794
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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