SAFETY Act Block Designation

Support Anti-terrorism by Fostering Effective Technologies Act of 2002

Documents and Forms

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

Information Collection (IC) Details

IC Title:	SAFETY Act Block Designation	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection 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: 20	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	20	-10	20	10
Annual IC Time Burden (Hours)	200	-500	200	500
Annual IC Cost Burden (Dollars)	0	-6,816	6,816	0

Documents for IC

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.