Information Collection

Authorization for Release of Records (Form A-5 & A-5s) - Record keeping

IC 249480 under ICR 202109-0970-014 · 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⚠️ Notice: This information collection may be referencing outdated material.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-5 Authorization for Release of Records (Form A-5) - Record keeping Form
A-5 Authorization for Release of Records Authorization for Release of Records (Form A-5) - PDF.pdf Form
A-5 Authorization for Release of Records A-5 Authorization for Release of Records 04.08.22.pdf Form
A-5s Authorization for Release of Records - Spanish A-5s Authorization for Release of Records - final 05.03.22.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Authorization for Release of Records (Form A-5 & A-5s) - Record keeping	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	A-5	Authorization for Release of Records	A-5 Authorization for Release of Records 04.08.22.pdf		Yes	Yes	Fillable Fileable
Form	A-5s	Authorization for Release of Records - Spanish	A-5s Authorization for Release of Records - final 05.03.22.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: 216	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	4,104	104	4,000
Annual IC Time Burden (Hours)	1,368	368	1,000
Annual IC Cost Burden (Dollars)	0	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.