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

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 and Security Complaints expires 2022-11-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form 0945-0002 Civil Rights and Conscience Complaint Form
10-31 updated to add annualized cost per PRA officer Final 7-7-22 Supporting document HH.docx Supporting Statement A
Civil Rights and Conscience Complaint Form
Health Information Privacy and Security Complaint Other-form

All Historical Document Collections

202209-0945-001 Approved with change	Extension without change of a currently approved collection	2022-10-31
201906-0945-004 Approved without change	Revision of a currently approved collection	2019-06-25
201710-0945-003 Approved with change	No material or nonsubstantive change to a currently approved collection	2017-11-07
201512-0945-001 Approved without change	Extension without change of a currently approved collection	2015-12-30
201301-0945-001 Approved with change	Extension without change of a currently approved collection	2013-01-17

OMB Details

Complaint Forms for Discrimination; Health Information Privacy Complaints

Federal Enterprise Architecture: Health - Health Care Services