OMB control number
Complaint Forms for Civil Rights and Conscience; Health Information Privacy Security and Breach Notification Complaints
OMB 0945-0002 · HHS/OCR.
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 can be found here.
Document Name |
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Form |
Form |
Supporting Statement A |
Form HHS-700 Civil Rights and Conscience Complaint
OMB Submission_Supporting Statement for OMB 0945-0002_03012 final 30-day.docx
Civil Rights and Conscience Complaint | Revision of a currently approved collection | 2026-03-05 | ||
|
Approved with change |
Extension without change of a currently approved collection | 2022-10-31 | |
|
Approved without change |
Revision of a currently approved collection | 2019-06-25 | |
|
Approved with change |
No material or nonsubstantive change to a currently approved collection | 2017-11-07 | |
|
Approved without change |
Extension without change of a currently approved collection | 2015-12-30 | |
|
Approved with change |
Extension without change of a currently approved collection | 2013-01-17 |
Health Information Privacy, Security and Breach Notification Complaint
Federal Enterprise Architecture: Health - Illness Prevention
| 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.