Individual Notice Written and E-mail Notice

HITECH Act Breach Notification

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0945-0001 can be found here:

Documents and Forms

Document Name Document Type
0990-BreachPRA Supplementary Statement.doc 0990-BreachPRA Supplementary Statement IC Document

Information Collection (IC) Details

IC Title:	Individual Notice Written and E-mail Notice	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 45 CFR 160

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 106	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	106	106
Annual IC Time Burden (Hours)	21,836	21,836
Annual IC Cost Burden (Dollars)	722,178	722,178

Documents for IC

Title	Document	Date Uploaded
0990-BreachPRA Supplementary Statement	0990-BreachPRA Supplementary Statement.doc	12/23/2009

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