Request for Exemption of Select Agent and Toxin for an Investigational Product (APHIS/CDC Form 5)

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⚠️ Notice: This information collection may be referencing outdated material.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 0920-0576 Request for Exemption of Select Agent Agent and Toxin for an Investigational Product (APHIS/CDC Form 5) Form
0920-0576 Request for Exemption Att7 - Request for Exemptionv1.docx Form
0920-0576 Request for Exemption Att7 - Request for Exemptionv1.docx Form

Information Collection (IC) Details

IC Title:	Request for Exemption of Select Agent Agent and Toxin for an Investigational Product (APHIS/CDC Form 5)	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	0920-0576	Request for Exemption	Att7 - Request for Exemptionv1.docx		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: 1	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1	1
Annual IC Time Burden (Hours)	1	1
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.