View Information Collection (IC)

View Information Collection (IC)

Complaint Forms for Discrimination; Health Information Privacy Complaints
No Modified

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-form 0945-0002 CivilRightscomplaintform HH 12-3-15.pdf Yes Yes Fillable Fileable

Health Health Care Services


3,493 0
Individuals or Households
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 3,493 0 0 0 0 3,493
Annual IC Time Burden (Hours) 2,620 0 0 0 0 2,620
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.