Information Collection

Significant Incident Report (Form A-10C)

IC 241076 under ICR 202105-0970-013 · 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⚠️ Notice: This information collection may be referencing outdated material.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-10C Significant Incident Report (Form A-10C)	Form
A-10C Significant Incident Report Significant Incident Report.pdf	Form
A-10C Significant Incident Report Significant Incident Report.pdf	Form

IC Title:

Significant Incident Report (Form A-10C)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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-10C	Significant Incident Report	Significant Incident Report.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: 80,340

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	Previously Approved
Annual Number of Responses for this IC	80,340	80,340
Annual IC Time Burden (Hours)	26,780	26,780
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.