Information Collection

Significant Incident Report Addendum (Form A-10D)

IC 241077 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form A-10D Significant Incident Report Addendum (Form A-10D) Form
A-10D Significant Incident Report Addendum Significant Incident Report Addendum (Form A-10D).pdf Form
A-10D Significant Incident Report Addendum Significant Incident Report Addendum (Form A-10D).pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Significant Incident Report Addendum (Form A-10D)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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	A-10D	Significant Incident Report Addendum	Significant Incident Report Addendum (Form A-10D).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: 25,630	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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	25,630	25,630
Annual IC Time Burden (Hours)	6,408	6,408
Annual IC Cost Burden (Dollars)	0	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.