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

Possession, Use, and Transfer of Select Agents and Toxins (42 CFR 73)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form APHIS/CDC FORM 3 Incident Form to Report Potential Theft, Loss, Release, or Occpational Exposure Form and Instruction
APHIS/CDC FORM 3 INCIDENT FORM TO REPORT POTENTIAL THEFT, LOSS, RELEASE, Att19 - Notification of Theft Loss or Releasev1.docx 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

Information Collection (IC) Details

IC Title:	Incident Form to Report Potential Theft, Loss, Release, or Occpational Exposure	Agency IC Tracking Number:	0920-0576

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

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	APHIS/CDC FORM 3	INCIDENT FORM TO REPORT POTENTIAL THEFT, LOSS, RELEASE, OR OCCUPATIONAL EXPOSURE	Att19 - Notification of Theft Loss or Releasev1.docx	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: 201	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	201	-4	205
Annual IC Time Burden (Hours)	201	-107	308
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.