Information Collection

Civil Rights and Conscience Complaint

IC 236663 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 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

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 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 %

table that charts list of burden
	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

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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].