Information Collection

Emergency Significant Incident Report (Form A-10A)

IC 241074 under ICR 202004-0970-002 · OMB 0970-0547.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0547 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form A-10A Emergency Significant Incident Report (Form A-10A)	Form
A-10A Emergency Significant Incident Report Emergency Significant Incident Report (Form A-10A).pdf	Form

IC Title:

Emergency Significant Incident Report (Form A-10A)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	A-10A	Emergency Significant Incident Report	Emergency Significant Incident Report (Form A-10A).pdf		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,640

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,640	1,640
Annual IC Time Burden (Hours)	547	547
Annual IC Cost Burden (Dollars)	0	0

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.