Information Collection

Incident Form to Report Potential Theft, Loss, Release, or Occpational Exposure

IC 217520 under ICR 201804-0920-015 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Incident Form to Report Potential Theft, Loss, Release, or Occpational Exposure	Form and Instruction
Incident Notification and Reporting APHIS/CDC Form 3 (Th Att4-Form3.pdf	Form and Instruction
APHIS/CDC FORM 3 INCIDENT FORM TO REPORT POTENTIAL THEFT, LOSS, RELEASE, Att3-Incident Notification and Reporting - Form3.pdf www.selectagents.gov/form3.html	Form and Instruction
APHIS-CDC_Form_3_English_Fillable.pdf Drop down list	IC Document
Att3a - Form3-SATRN Screenprints.docx APHIS/CDC Form 3,(screenshots)	IC Document

IC Title:

Incident Form to Report Potential Theft, Loss, Release, or Occpational Exposure

Agency IC Tracking Number:

0920-0576 18FL

Is this a Common Form? No

IC Status: Unchanged

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
Form and Instruction	APHIS/CDC FORM 3	INCIDENT FORM TO REPORT POTENTIAL THEFT, LOSS, RELEASE, OR OCCUPATIONAL EXPOSURE	Att3-Incident Notification and Reporting - Form3.pdf	http://www.selectagents.gov/form3.html	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	Previously Approved
Annual Number of Responses for this IC	205	205
Annual IC Time Burden (Hours)	308	308
Annual IC Cost Burden (Dollars)	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
APHIS/CDC Form 3,(screenshots)	Att3a - Form3-SATRN Screenprints.docx	12/18/2017

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