Information Collection

Incident Reviews (Forms M-5A to M-5B)

IC 245580 under ICR 202112-0970-003 · OMB 0970-0564.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0564 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form M-5A Incident Reviews (Forms M-5A to M-5B)	Form and Instruction
Form M-5A UC Incident Review UC Incident Review (Form M-5A).pdf	Form and Instruction
Form M-5A UC Incident Review UC Incident Review (Form M-5A).pdf	Form and Instruction
Form M-5B Adult Incident Review Adult Incident Review (Form M-5B).pdf	Form and Instruction
Form M-5B Adult Incident Review Adult Incident Review (Form M-5B).pdf	Form and Instruction

IC Title:

Incident Reviews (Forms M-5A to M-5B)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	Form M-5A	UC Incident Review	UC Incident Review (Form M-5A).pdf		Yes	Yes	Fillable Fileable
Form and Instruction	Form M-5B	Adult Incident Review	Adult Incident Review (Form M-5B).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: 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	65	65
Annual IC Time Burden (Hours)	97	97
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.