Information Collection

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

IC 217520 under ICR 202109-0920-003 · OMB 0920-0576.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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, APHIS-CDC Form 3_clean version_2021-08-17.docx www.selectagents.gov/form3.html	Form and Instruction
APHIS/CDC FORM 3 INCIDENT FORM TO REPORT POTENTIAL THEFT, LOSS, RELEASE, APHIS-CDC Form 3_clean version_2021-08-17.docx www.selectagents.gov/form3.html	Form and Instruction
APHIS-CDC_Form_3_English_Fillable.pdf Drop down list	IC Document
APHIS-CDC_Form_3_English_Fillable.pdf Drop down list	IC Document
Att3a - Form3-SATRN Screenprints.docx APHIS/CDC Form 3,(screenshots)	IC Document
Att3a - Form3-SATRN Screenprints.docx APHIS/CDC Form 3,(screenshots)	IC Document

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:

table that charts list of 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	APHIS-CDC Form 3_clean version_2021-08-17.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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	201	201
Annual IC Time Burden (Hours)	201	201
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.