Information Collection

Identifying breach, affected customers, notifying customers, etc.

IC 188848 under ICR 201208-3084-004 · OMB 3084-0150.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3084-0150 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Updated Breach Notification Form 8 -24-12.pdf Health Breach Notification Form	IC Document

IC Title:

Identifying breach, affected customers, notifying customers, etc.

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 16 CFR 318

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Economic Development

Subfunction: Business and Industry Development

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 90 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2	-9	11
Annual IC Time Burden (Hours)	200	-900	1,100
Annual IC Cost Burden (Dollars)	7,918	-98,552	106,470

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Health Breach Notification Form	Updated Breach Notification Form 8 -24-12.pdf	08/24/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.