Information Collection

Civil Rights and Conscience Complaint

IC 236663 under ICR 202512-0945-001 · OMB 0945-0002.

Documents and Forms

Document Name Document Type
Form HHS-700 Civil Rights and Conscience Complaint Civil Rights and Conscience Complaint Form
HHS-700 Civil Rights and Conscience Complaint Clean CR Complaint Form edits_021726.pdf ocrportal.hhs.gov/ocr/smartscreen/main.jsf Form

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HHS-700	Civil Rights and Conscience Complaint	Clean CR Complaint Form edits_021726.pdf	https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 15,468	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	15,468	22	15,446
Annual IC Time Burden (Hours)	11,618	33	11,585
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.

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