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OMB Control No: 0945-0002	ICR Reference No: 202512-0945-001
Status: Received in OIRA	Previous ICR Reference No: 202209-0945-001
Agency/Subagency: HHS/OCR	Agency Tracking No:
Title: Complaint Forms for Civil Rights and Conscience; Health Information Privacy Security and Breach Notification Complaints
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 03/05/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	04/30/2026
Responses	47,453	45,838
Time Burden (Hours)	35,607	34,379
Cost Burden (Dollars)	0	0

ICR Summary of Burden

	Total Request	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	47,453	45,838	1,615
Annual Time Burden (Hours)	35,607	34,379	1,228
Annual Cost Burden (Dollars)	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Based on examination of actual complaint levels over the past two years, OCR projects that OCR will average 15,468 civil rights related complaints per year and 31,985 privacy related complaints per year.

Annual Cost to Federal Government:

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

Agency Contact: Harold Henderson 202 868-9407 harold.henderson@hhs.gov

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