OMB control number

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

OMB 0945-0002 · HHS/OCR.

OMB 0945-0002

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.

The latest form for Complaint Forms for Civil Rights and Conscience; Health Information Privacy Security and Breach Notification Complaints expires 2029-05-31 and is listed under ICR 202512-0945-001.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
Document	Type
Form HHS-700 Civil Rights and Conscience Complaint	Form
Form HHS-700 Health Information Privacy, Security and Breach Notification Complaint	Form
OMB Submission_Supporting Statement for OMB 0945-0002_03012 final 30-day.docx	Supporting Statement A
Civil Rights and Conscience Complaint	Form
Civil Rights and Conscience Complaint	Form
Health Information Privacy, Security and Breach Notification Complaint	Form
Health Information Privacy, Security and Breach Notification Complaint	Form

All Historical Document Collections

Historical document collections
Reference	Filing	Received	Action
202512-0945-001	Revision of a currently approved collection	2026-03-05
202209-0945-001	Extension without change of a currently approved collection	2022-10-31	Approved with change
201906-0945-004	Revision of a currently approved collection	2019-06-25	Approved without change
201710-0945-003	No material or nonsubstantive change to a currently approved collection	2017-11-07	Approved with change
201512-0945-001	Extension without change of a currently approved collection	2015-12-30	Approved without change
201301-0945-001	Extension without change of a currently approved collection	2013-01-17	Approved with change

OMB Details

Health Information Privacy, Security and Breach Notification Complaint

Federal Enterprise Architecture: Health - Illness Prevention

Information collection instruments
Form	Name	Electronic access	Type
Form HHS-700	Health Information Privacy, Security, and Breach Notification	ocrportal.hhs.gov/ocr/smartscreen/main.jsf	Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.