Information Collection

Identifying breach, affected customers, notifying customers, etc.

IC 188848 under ICR 201601-3084-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Form Not Applicable Identifying breach, affected customers, notifying customers, etc.	Form and Instruction
Not Applicable Notice of Breach of Health Information Health Breach Notification Rule Form - 2015-2016.pdf www.ftc.gov/healthbreach	Form and Instruction

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
Form and Instruction	Not Applicable	Notice of Breach of Health Information	Health Breach Notification Rule Form - 2015-2016.pdf	http://www.ftc.gov/healthbreach	Yes	Yes	Fillable Fileable Signable

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	0	2
Annual IC Time Burden (Hours)	3,267	3,067	200
Annual IC Cost Burden (Dollars)	49,960	42,042	7,918

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.