Information Collection

Report of Theft, Loss, or Release of Select Agent or Toxin (APHIS/CDC Form 3)

IC 217520 under ICR 201706-0920-009 · OMB 0920-0576.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0576 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Report of Theft, Loss, or Release of Select Agent or Toxin (APHIS/CDC Form 3)	Form and Instruction
Incident Notification and Reporting APHIS/CDC Form 3 (Th Att4-Form3.pdf	Form and Instruction
APHIS-CDC_Form_3_English_Fillable.pdf Drop down list	IC Document

IC Title:

Report of Theft, Loss, or Release of Select Agent or Toxin (APHIS/CDC Form 3)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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	NA	Incident Notification and Reporting APHIS/CDC Form 3 (Theft/Loss/Release)	Att4-Form3.pdf	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: 09-20-0170 National Select Agent Registry/Select Agent Transfer and Entity Registration Information System

FR Citation: 76 FR 4483

Number of Respondents: 205

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	205	-225	430
Annual IC Time Burden (Hours)	308	-122	430
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Drop down list	APHIS-CDC_Form_3_English_Fillable.pdf	12/01/2016

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