Information Collection Request

Health Breach Notification Rule

ICR 201905-3084-001 · OMB 3084-0150 · Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form Not Applicable Major Breaches Form and Instruction New Repair queued
Form Not Applicable Single-person Breaches Form and Instruction Modified Available
Health Breach Notification Rule - SS - 2019 - FINAL.pdf Supporting Statement A Uploaded 2019-05-02 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
235941 Major Breaches Form and Instruction New
188848 Single-person Breaches Form and Instruction Modified

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
06/30/2022 36 Months From Approved 06/30/2019
25,001 0 2
4,779 0 3,267
29,952 0 49,960





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table that charts list of burden
IC Title Form No. Form Name
Single-person Breaches Not Applicable Notice of Breach of Health Information
Major Breaches Not Applicable Notice of Breach of Health Information

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 25,001 2 0 0 24,999 0
Annual Time Burden (Hours) 4,779 3,267 0 0 1,512 0
Annual Cost Burden (Dollars) 29,952 49,960 0 0 -20,008 0


Reginfo record details
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