Civil Rights and Conscience Complaint

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

Documents and Forms

Document Name Document Type
Form 0945-0002 Civil Rights and Conscience Complaint Form
0945-0002 Civil Rights and Conscience Complaint Form Final 7-7-22 CR-CRF HH.docx Form
0945-0002 Civil Rights and Conscience Complaint Form Final 7-7-22 CR-CRF HH.docx Form

Information Collection (IC) Details

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	0945-0002	Civil Rights and Conscience Complaint Form	Final 7-7-22 CR-CRF HH.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 15,446	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	15,446	7,013	8,433
Annual IC Time Burden (Hours)	11,585	5,260	6,325
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.