Information Collection

Individual Notice Written and E-mail Notice

IC 190795 under ICR 201302-0945-002 · OMB 0945-0001.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0990-BreachPRA Supplementary Statement.doc 0990-BreachPRA Supplementary Statement	IC Document

IC Title:

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:

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: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 19,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	19,000	18,894	106
Annual IC Time Burden (Hours)	9,500	-12,336	21,836
Annual IC Cost Burden (Dollars)	1,710,000	987,822	722,178

Documents for IC

table that charts IC Documents
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.