Information Collection

Reporting the Identification of a Select Agent or Toxin from a Clinical/Diagnostic Specimen (Form 4)

IC 217505 under ICR 202203-0920-007 · 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⚠️ Notice: This information collection may be referencing outdated material.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 4A Reporting the Identification of a Select Agent or Toxin from a Clinical/Diagnostic Specimen (Form 4)	Form and Instruction
4A Reporting the Identification of a Select Agent or Toxin APHIS-CDC_Form_4-clean version.docx	Form and Instruction
APHIS-CDC_Form_4-tracked changes.docx Minor Changes to Form 4 (March 2022)	IC Document

IC Title:

Reporting the Identification of a Select Agent or Toxin from a Clinical/Diagnostic Specimen (Form 4)

Agency IC Tracking Number:

0920-0576 18FL

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	4A	Reporting the Identification of a Select Agent or Toxin from a Clinical/Diagnostic Specimen	APHIS-CDC_Form_4-clean version.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: 1,181

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	1,181	1,181
Annual IC Time Burden (Hours)	1,181	1,181
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Minor Changes to Form 4 (March 2022)	APHIS-CDC_Form_4-tracked changes.docx	03/21/2022

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.