Information Collection

SAFETY Act Block Designation

IC 190458 under ICR 201501-1640-002 · OMB 1640-0001.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1640-0001 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DHS Form 10005 SAFETY Act Block Designation	Form and Instruction
DHS Form 10005 SAFTEY Act Block Designation 10005_SAFETY_Act_Block_Designation.pdf www.safetyact.gov	Form and Instruction

IC Title:

SAFETY Act Block Designation

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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
Form and Instruction	DHS Form 10005	SAFTEY Act Block Designation	10005_SAFETY_Act_Block_Designation.pdf	www.safetyact.gov	Yes	Yes	Fillable Fileable

Line of Business: Homeland Security

Subfunction: Key Asset and Critical Infrastructure Protection

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	10	10
Annual IC Time Burden (Hours)	500	500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.